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GENIW^RINARY  SYSTEM 

#IN  THE  MALE 

«==;'  WITH 

STERILITY  AND  IMPOTENCE 


DR.  R.  ULTZMANN 

Professor  or  Genito-Urinary  Diseases  m  the  University  of  Vienna 


SECOND  EDITION,  REVISED 

WITH   NOTES   AND   A   SUPPLEMENTARY   ARTICLE   ON 

NERVOUS  IMPOTENCE 

BY    THE   TRANSLATOR 

GARDNER  W.  ALLEN,  M.D. 

Surgeon  in  the  Genito-Urinary  Department  of  the  Boston  Dispensary  ; 
Instructor  in  Genito-Urinary  Surgery  in  Tufts  Medical  School 


Philadelphia 

F.  A.  DAVIS  COMPANY,  PUBLISHERS 

]902 


!  1o^ 


COPYRIGHT,  1890, 

BY 

GARDNER  W.  AI-LEN,  M.D. 
COPYRIGHT,  1902, 

BY 

F.  A.  DAVIS  COMPANY. 


Philadelrhia,  Pa.,  U.  S.  A. : 

riie  Medical  Bulletin  Printing-hoaso, 

1916  Cherry  Street. 


PREFACE  TO  REVISED  EDITION. 


Although  it  is  now  several  years  since  Ultz- 
mann  wrote  these  monographs,  and  we  must 
greatly  regret  that  he  did  not  live  to  revise  his 
own  work,  yet  his  knowledge  of  the  subject  was 
so  profound  that  comparatively  little  has  been 
added  to  it  during  the  interval,  except  in  certain 
points  relating  to  sexual  disorders.  In  the  pres- 
ent edition  a  supplementary  article  treats  some- 
what more  at  length  the  nervous  form  of  impo- 
tence. A  few  notes  also  have  been  added  to  the 
book.  It  is  believed  that  this  new  matter  brings 
the  subject  down  to  the  present  day. 


^3) 


TRANSLATOR'S   NOTE. 

This  translation,  published  with  the  author's 
permission,  is  of  the  two  monographs,  "  Ueber 
die  Neuropathien  (Neurosen)  des  mannlichen 
Harn-  und  Geschlechtsapparates  "  and  "  Ueber 
Potentia  generandi  und  Potentia  coeundi."  It 
is  hoped  that  a  wider  circulation  than  has  here- 
tofore been  accorded  in  this  country  to  the 
sound  pathological  teachings  and  successful 
methods  of  treatment  of  so  eminent  an  autho- 
rity as  Prof.  Ultzmann  will  throw  light  on 
the  management  of  this  very  difficult  and  re- 
fractory class  of  cases. 

Inasmuch  as  the  two  parts  treat  of  kindred 

subjects  there  is  some  necessary  repetition  in 

the  original.     This   has   been    to  some    extent 

avoided  by  slightly  abridging  the  second  part. 

The  omissions  are  indicated  by  references  to  the 

first  part. 

G.  W.  A. 


(4) 


CONTENTS. 


PART  I. 

PAGE 

Introduction, T 

The  Urine  in  Genito-Urinary  Neuroses,     .  1 2 

Classification, 24 

1.  Sensory  Neuroses: 

(a)  of  the  Urinary  System,     .         .  25 

{b)  of  the  Sexual  System,       .         .  31 

2.  Motor  Neuroses: 

(a)  of  the  Urinary  System,     .         .  43 

(&)  of  the  Sexual  System,       .         .  81 

3.  Secretory  Neuroses: 

(a)  of  the  Urinary  System,     .         .  103 

(b)  of  the  Sexual  System,        .         .  104 

PART  II. 

Introduction, Ill 

Sterility, Ill 

Impotence,      .        .        .         .        .         .        .140 

ISTOTES, 161 

Nervous  Impotence, 163 

Etiology, 166 

Pathology, ^4 

Prognosis, .118 

Treatment, I'TO 

Index, 191 


(5) 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/neurosesofgenit1902ultz 


THE   NEUROSES   OF  THE   GENITO- 
URINARY SYSTEM  IN  THE  MALE. 


TPHE  neuroses  of  the  male  urinary  and  sex- 
-*■  ual  system  belong  among  the  more  fre- 
quent forms  of  disease.  Although  the  nervous 
diseases  of  the  urinary  system,  as  well  as  those 
of  the  sexual  organs,  may  occur  alone,  still  we 
find  not  infrequently  several  forms  of  nervous 
disease  of  both  systems  in  the  same  individual, 
usually  united  by  one  and  the  same  setiological 
origin,  so  that  it  seems  best  to  treat  of  the  neu- 
roses of  the  urinary  and  of  the  genital  organs 
in  the  same  connection. 

The  aetiology  of  this  class  of  disease  may 
vary  greatly.  Now  it  is  to  be  sought  in  local 
changes  of  the  so-called  neck  of  the  bladder 
(prostatic  urethra),  and  now  in  general  disturb- 
ances of  nutrition. 

The  general  disturbances  of  nutrition  appear 
sometimes  in  consequence  of  chronic  brain  and 
spinal  affections,  or  they  consist  in  that  exalted, 
abnormal  reflex  excitability,  sometimes  inherited 
and  congenital,  usually,  however,  associated 
with  anaemia  and  a  feeble  constitution.     Per- 

(7) 


8        Neivroses  of  the  Genito-Urinary  System 

sons  of  a  perfectly  normal  constitution  may 
nevertheless  acquire  an  exalted  reflex  excitabil- 
ity, which  disposes  to  neurosis  of  the  genito- 
urinary system,  if  they  weaken  their  organism 
by  overstrained  physical,  but  especially  by 
exciting  mental,  activity  long  kept  up.  Not 
infrequently,  indeed,  we  find  nervous  vesical 
tenesmus  (cystospasmus)  in  persons  who  have 
exacting  night  work  to  do,  or  in  individuals 
who,  in  addition  to  severe  mental  activity,  hold 
an  unusually  responsible  position,  as  with  cash- 
iers, secretaries,  and  such  persons.  Even  so 
also  the  cares  of  life  engender  the  most  varied 
neuroses  in  the  urinary  system.  Still  further, 
shocks  to  the  general  nervous  system,  great 
fright,  pain,  and  grief,  give  rise  to  nervous  dis- 
turbances as  well  of  the  urinary  as  of  the  sexual 
functions.  The  immediate  influence  of  the  cen- 
tral nervous  system  on  the  urinary  apparatus 
may  even  be  observed  in  children,  when  they 
from  fear  of  threatened  punishment  pass  urine 
involuntarily  in  their  clothes.  Likewise  we  see 
vesical  tenesmus  with  polyuria  show  itself  in 
individuals  who  keep  themselves  in  a  state  of 
long-continued  excitement ;  as,  for  instance, 
candidates  before  severe  examinations,  when 
the  result  is  uncertain,  or  in  persons  who  have 
engaged  in  a  mercantile  speculation  of  doubt- 
ful outcome.  Great  and  unexpected  loss  of 
property,  such  as  sometimes  occurs  in  unfort- 


in  the  Male.  9 

unate  stock  operations,  or  the  death  of  a  be- 
loved person,  may  also  cause  the  most  varied 
nervous  phenomena  in  the  urinary  and  sexual 
apparatus.  Thus  I  have  often  seen  in  the  case 
of  seriously  damaged  business-men  frequent 
micturition,  polyuria,  sometimes  even  slight 
glycosuria,  and,  further,  sexual  impotence,  emis- 
sions, and  spermatorrhoea  suddenly  appear. 

A  much  larger  contingent  in  these  nervous 
cases,  however,  is  furnished  by  those  manifesta- 
tions of  disease  which  have  their  origin  in  local 
changes  in  the  urinary  system,  and  which  con- 
sequently are  to  be  looked  upon  as  reflex  neu- 
roses. In  this  connection,  the  most  harmful 
influence  on  the  urethra  and  on  the  prostate  is 
exercised  by  the  gonorrhceal  process.  A  gonor- 
rhoea, which  runs  a  normal  course,  begins  at  the 
orifice  of  the  urethra,  and  ends  at  the  beginning 
of  the  sphincter  vesicae  externus.  If,  however, 
an  abnormal  course  sets  in,  if  the  gonorrhoea 
extends  beyond  the  isthmus  urethrse,  then,  in 
the  first  place,  the  prostate  is  involved  by  sym- 
pathy ;  it  becomes  catarrhal ;  and  if  prostatic 
catarrh  once  becomes  chronic,  then  various  ner- 
vous symptoms  gradually  arise,  now  in  the  urin- 
ary, now  in  the  sexual  system.  Likewise  local- 
ized hypersemia  occurs,  and  even  prostatic 
catarrh,  around  the  verumontanum  after  gross 
excesses  in  venery  and  after  masturbation.  In 
this  case,  through  long-continued  and  too  often 
1* 


10     Neuroses  of  the  Genito-Urinary  System 

repeated  sexual  excitement,  the  congestion  of 
the  prostatic  urethra  and  especially  of  the  caput 
gallinaginis  is  so  long  kept  up  that  ir.  has  finally 
become  localized  there  as  a  chronic  affection,  and 
a  catarrhal  condition  of  the  prostatic  ducts,  of 
the  sinus  pocularis,  and  of  the  ejaculatory  ducts 
has  established  itself.  This  hyperiemic  and 
chronically  inflamed  condition  of  the  prostatic 
urethra  sometimes  has,  as  a  consequence,  a  gen- 
eral exalted  reflex  excitability,  a  high  degree  of 
nervousness,  and  sometimes  we  find  in  men 
phenomena  which  usually  appear  only  in  in- 
tensely hysterical  women.  Since  many  women, 
ill  with  nervous  and  hysterical  affections,  suffer 
from  abnormalities  of  the  uterus  associated  with 
cervical  catarrh,  it  will  not  seem  strange  to  us 
if  men  who  suffer  from  chronic  congestive  or 
inflammatory  processes  of  the  prostate  present 
similar  nervous  phenomena,  especially  as  the 
prostate  with  the  utriculus  masculinus  is,  in 
men,  that  organ  which  finds  its  analogue  in  the 
female  uterus. 

The  exact  connection  between  the  nervous 
system  and  the  functions  of  the  urinary  and 
sexual  apparatus  is  still  very  little  understood; 
yet  we  know  from  Eckhard  and  Goltz  that  the 
centres  for  the  nerves  which  preside  over  erec- 
tion, for  instance,  are  to  be  sought  in  the  lum- 
bar region  of  the  spinal  cord.  Also  the  secre- 
tion of  semen,  the  action  of  the  vasa  deferentia 


in  the  Male.  11 

and  of   the  vesiculse  seminales,  are  under  the 
influence  of  the  spinal  cord. 

The  prostate  and  the  uterus  are  both  struc- 
tures very  rich  in  nerves,  and  they  are  inner- 
vated by  one  and  the  same  nerve-plexus.  The 
hypogastric  plexus  of  the  sympathetic,  which  is 
reinforced  by  filaments  from  the  sacral  ganglia 
and  from  the  pudendal  plexus  of  the  sacral 
nerves,  innervates  the  uterus  in  women  by 
means  of  its  accessory  plexus,  the  plexus  uter- 
inus,  and  in  men  the  seminal  vesicles  and  pros- 
tate, together  with  the  bladder,  by  means  of 
the  plexus  vesicalis.  In  the  uterus,  according 
to  Kilian,  the  nerves  are  found  in  greater  num- 
ber in  the  cervix,  and  according  to  Klein,  we 
find  especially  numerous  nerve-trunks  in  the 
prostate  between  the  sphincter  urethrse  and  the 
circular  striped  muscular  fibres  of  the  cortical 
layer,  which  extend  along  the  urethra,  and  hold 
scattered  between  their  fibres  numerous  gang- 
lion cells.  The  prostate  also  contains  in  its 
cortical  layer  ganglia  and  Pacinian  corpuscles, 
which  are  elsewhere  only  present  in  organs  very 
sensitive  and  rich  in  nerves.  Since  the  hypo- 
gastric plexus  of  the  sympathetic  is  in  intimate 
connection  with  the  pudendal  plexus  of  the 
spinal  nerves,  and  this  latter  presents  a  sub- 
ordinate plexus  of  sacral  nerves,  which  again, 
on  their  side,  stand  in  the  closest  relation 
with  the  lumbar   nerves;    so,  when  in  organs 


12     Neuroses  of  the  Genito- Urinary  System 

very  rich  in  nerves,  such  as  the  uterus  and 
prostate,  the  peripheral  terminations  of  the 
nerves  are  kept  in  a  constant  state  of  excite- 
ment by  chronic  inflammatory  processes,  it  ap- 
pears very  clear  that  by  transmission  of  this 
irritation  to  other  nerves  in  the  area  supplied 
by  ramifications  of  the  nerves  belonging  to  the 
plexi  mentioned,  neuroses  of  the  most  varied 
cliaracter  may  appear  in  the  genito-urinary 
tract.  In  like  manner  worms  —  Oxyuris  vermi- 
cularis,  —  eczema,  and  catarrhal  ulcers  of  the 
anus  produce  by  transmission  neuroses  of  the 
urinary  and  sexual  apparatus  as  well  as  general 
reflex  excitability. 

The  pathological-anatomical  records  in  this 
connection  are  very  scanty.  Kaula  has  col- 
lected several  autopsy  reports,  and  has  found 
organic  changes  as  follows:  sometimes  the  re- 
sults of  chronic,  in  part  suppurative,  inflamma- 
tion, with  ulceration,  in  the  pars  prostatica 
urethrce,  which  extends  to  the  ejaculatory  ducts 
and  the  vesiculse  seminales,  sometimes  changes 
in  the  ejaculatory  ducts,  widening  of  their  ori- 
fices and  dilatation  of  their  lumen,  sometimes 
strictures,  inflammation  of  the  neck  of  the  blad- 
der, total  or  partial  hypertrophy  of  the  prostate, 
or,  on  the  other  hand,  atrophy  of  the  prostate 
(Curschmann). 

The  Urine  in  neuroses  in  general,  and  espe- 
cially in    those    of   the   genito-urinary   system, 


in  the  Male.  13 

offers  sometimes  such  characteristic  conditions 
that  an  exact  knowledge  of  them  materially 
aids  in  diagnosis.  First  of  all  it  is  to  be  no- 
ticed that  patients  who  are  affected  with  neu- 
roses not  infrequently  suffer  at  the  same  time 
with  polyuria.  They  urinate  often,  yet  have  no 
pain  or  inconvenience  except  that  they  have  to 
produce  so  much  urine.  The  urine  of  polyuria 
is  of  a  pale  straw  color,  and  clear,  with  a  low 
specific  gravity  (urina  spastica,  nervosa,  diluta). 
Yet  sometimes  there  is  a  great  quantity  of  urine 
without  the  specific  gravity  of  the  urine  being 
diminished  in  a  corresponding  proportion.  In 
this  case  there  is  at  the  same  time  an  increased 
excretion  of  solids,  a  diabetes  insipidus.  This 
I  have  observed  in  a  13-year-old  anaemic  and 
excitable  boy,  who  daily  passed  7  litres  of  color- 
less urine,  almost  as  clear  as  water,  of  which 
the  specific  gravity  was  1.005.  The  24-hour 
quantity  of  solids  amounted  to  81  grammes. 
The  patient  was  always  thirsty,  and  was  at  any 
time  ready  to  pass  400  or  500  c.c.  of  urine. 
Sugar  was  not  present. 

It  has  been  known  since  Claude  Bernard  that 
a  puncture  in  the  floor  of  the  fourth  ventricle, 
and,  indeed,  in  a  small  circumscribed  spot  be- 
tween the  origin  of  the  vagi  and  that  of  the 
acoustic  nerves,  produces  polyuria,  and  at  the 
same  time  glycosuria.  It  has  also  been  found 
that  certain  changes  in  the  central  nervous  sys- 


14     Neuroses  of  the  Crenito-  Urinary  System 

tern  are  accompanied  by  polyuria  and  glycos- 
uria. 

If  the  puncture  fails  to  cause  glycosuria,  there 
is  still  usually  polyuria.  It  is  not  uncommon 
also  to  find  polyuria  in  patients  who  are  suffer- 
ing from  an  affection  of  the  central  nervous 
S3'stem.  Lecorch^  and  others  have  found  that  in 
diabetes  mellitus  there  is  an  increased  excretion 
of  nitrogenous  urinary  constituents,  that  is  to 
say,  an  accompanying  azoturia  or  diabetes  in- 
sipidus; and  I  have  had  repeated  opportunities  to 
convince  myself  that  the  light  forms  of  diabetes 
mellitus,  which  can  be  cured  by  an  exclusive 
meat  diet,  excrete  considerably  more  urea  and 
uric  acid  after  the  so-called  cure  than  other 
healthy  men ;  in  other  words,  they  still  suffer 
from  azoturia.  In  the  case  of  a  diabetic  patient 
who  passed  in  24  hours  4  litres  of  urine  contain- 
ing 5  per  cent,  of  sugar,  the  sugar  disappeared 
in  a  short  time  under  an  exclusive  meat  diet; 
yet  the  24-hour  amount  of  solids  in  the  urine 
was  100  grammes,  or  about  one-third  more  than 
normal. 

Polyuria  in  neurotic  cases  cannot  always  be 
explained  in  the  same  way,  still  it  is  generally 
associated  with  irritability.  By  experiments  on 
animals  we  find,  according  to  Claude  Bernard, 
that  after  each  puncture  the  abdominal  viscera 
appear  highly  congested. 

Much  more  seldom  we  find  in  nervous  trou- 


in  the  Male.  15 

bles  a  diminution  of  the  amount  of  urine,  that 
is,  oliguria  and  even  anuria.  Anuria  in  com- 
paratively healthy  persons  without  disease  of 
the  kidneys  I  have  never  observed  but  twice,  and 
both  times  in  hysterical  women.     In  these  cases 

1  could  draw  from  the  bladder  with  the  catheter 
a  very  small  quantity  only  of  urine  ;  the  anuria 
lasted  from  one  to  two  days.  Benedikt  reports 
such  a  case  in  a  hysterical  woman,  which  lasted 
eight  days.  I  have  not  yet  seen  nervous  anuria 
in  men. 

Sugar  is  not  infrequently  found  temporarily 
in  small  quantities  and  even  to  the  amount  of 

2  per  cent,  in  the  urine  of  neurotic  patients. 
A  patient  affected  with  impotence  and  general 
reflex  irritability  I  once  found  to  have  transient 
glycosuria  with  2  per  cent,  of  sugar.  Further, 
in  several  cases  after  violent  mental  disturbance 
a  mild  glycosuria  ensued  which  lasted  days  and 
weeks.  I  have  also  not  infrequently  observed 
the  presence  of  small  amounts  of  sugar  in  the 
urine  in  chronic  brain  and  spinal  diseases. 
Leudet  has  found  sugar  in  the  urine  in  the 
greatest  variety  of  cerebral  diseases.  Also, 
after  a  blow  on  the  head,  after  certain  drugs 
(curare,  morphine),  sugar  is  found  temporarily 
in  the  urine.  A  light  symptomatic  glycosuria,  - 
which  is  usually  transient,  is  a  common  occur- 
rence in  diseases  of  the  nervous  system,  and  the 
same  importance  is  by  no  means  to  be  attributed 


16      Neuroses  of  the  Ge)dto-Urinary  System 

to  it  as  to  diabetes  mellitus.  I  knew  an  old 
man  who  had  3  per  cent,  of  sugar  in  his  urine 
about  ten  years  ago.  He  had  no  other  diabetic 
symptoms,  and  he  visited  Karlsbad  yearly. 
Gradually  paralysis  of  the  bladder  had  come  on, 
and  three  years  ago  retention  of  urine  suddenly 
set  in.  I  was  consulted  at  this  time,  and  no 
longer  found  any  sugar,  nor  have  I  since  then, 
up  to  his  recent  death  (of  interstitial  nephritis), 
been  able  to  find  any  sugar  in  his  urine.  In 
this  case  the  glycosuria  appears  to  have  been  as- 
sociated with  the  development  of  paralysis  of  the 
bladder.  That  glycosuria  of  a  mild  form  is  also 
found  in  diseases  of  the  liver  and  portal  vein  is 
a  well-known  fact,  which  need  not  be  considered 
here. 

Very  often,  in  cases  of  neurosis,  the  freshly 
passed  urine  has  a  neutral  and  sometimes  even 
a  faintly  alkaline  reaction,  although  the  patient 
may  have  ingested  neither  alkalies  nor  mineral 
water,  nor  anything,  indeed,  which  could  explain 
the  reaction  of  the  urine.  Such  a  urine  is  usu- 
ally of  a  pale  wine-yellow  color  and  clear ;  and 
only  when  the  reaction  is  decidedly  alkaline 
does  it  seem  to  have  a  slightly  cloudy  turbidity. 

Carbonate  of  ammonia,  the  ordinary  alkali  of 
other  alkaline  urines,  is  not  present.  On  the 
contrary,  there  is  a  fixed  alkali,  generally  the 
carbonate  of  soda.  Cazeneuve  and  Livon  have 
succeeded  in  making  the  urine  of  dogs  alkaline 


in  the  Male.  17 

in  every  case  by  dividing  the  spinal  cord  in  the 
cervical  region.  According  to  Maly,  the  acid 
reaction  of  the  urine  is  brought  about  by  the 
separation  of  acid  salts  in  the  urinary  system 
(in  the  renal  tubules)  by  the  process  of  endos- 
mosis,  from  the  alkaline  mixture  of  inorganic 
salts  as  found  in  the  blood  serum.  Yet  according 
to  the  theory  of  secretion  as  taught  by  Baumann 
and  lately  by  Heidenhein  and  Wittich,  the  renal 
epithelium  is  the  structure  which  should  sepa- 
rate the  fixed  constituents  of  the  urine.  In  ac- 
cordance with  this  view  it  may  also  be  assumed 
that  the  renal  epithelium  is  the  structure  wliich 
prepares  acid  urine  from  alkaline  blood,  as 
indeed  is  accepted  also  by  Kiihne.  At  any  rate 
the  whole  secretion  of  urine,  as  we  have  already 
shown,  is  under  nervous  influence ;  it  is  no 
wonder  then  if  in  nervous  affections,  as  a  rule,  a 
disturbance  or  change  in  the  secretion  of  urine 
is  brought  about,  so  that  a  neutral  or  even 
faintly  alkaline  urine  is  excreted. 

An  essential  result  of  the  neutral  or  alkaline 
reaction  is  the  turbidity  which  such  urines 
assume  on  heating,  the  earth}/  phosphates  being 
precipitated.  Heller  has  already  remarked  this 
phenomenon,  and  has  designated  it  as  a  char- 
acteristic occurrence  in  diseases  of  the  nervous 
system.  Heller  calls  these  earthy  phosphates 
precipitated  by  heat  "bone-earth"  [Knochen- 
erde],  because  the  precipitation  shows  a  chemi- 


18      JVcuroscs  0)  the  Grenito-Urinary  System 

cal  compound  which  is  presented  by  the  earthy 
constituents  of  bone.  Phosplioric  acid  forms 
with  lime  and  magnesia  three  classes  of  salts, 
according  to  its  basicity.  First,  acid  salts,  when 
one  equivalent  of  acid  unites  with  one  equival- 
ent of  base  ;  these  salts  are  readily  soluble,  and 
are  present  in  all  acid  urines.  Second,  basic 
salts,  when  one  equivalent  of  acid  unites  with 
three  equivalents  of  base ;  these  salts  are  in- 
soluble, and  exist  in  alkaline  urine  in  the  form 
of  an  amorphous  sediment.  Lastly,  neutral 
salts,  when  one  equivalent  of  acid  unites  with 
two  equivalents  of  base ;  these  salts  are  some- 
what less  soluble  than  the  acid  salts,  and  are 
found  in  neutral  urine.  If  these  salts  are  m 
solution  in  neutral  urine,  the  simple  warming 
in  a  test-tube  is  enough  to  precipitate  them.  If, 
however,  they  are  in  the  sediment,  they  appear 
crystalline  in  contrast  to  the  basic  earthy  phos- 
phates. Since,  on  heating  the  urine,  albumen 
is  also  precipitated,  the  character  of  the  white 
precipitate  must  be  shown  by  the  addition  of  a 
drop  of  acetic  acid ;  the  earth}"-  phosphates  are 
immediately  dissolved,  while  a  precipitate  of 
albumen  remains  unchanged  on  the  addition 
of  acetic  acid.  If  the  precipitate  becomes  dis- 
solved with  an  active  development  of  gas,  it 
consists  of  a  mixture  of  carbonic  and  jjhosphatic 
salts  of  the  alkaline  earths  ;  if  it  dissolves  with- 
out the  production  of  gas,  it  consists  of  phos- 
phates alone. 


in  the  Male.  19 

Sometimes  there  is  an  increase  of  indiean  in 
the  urine  in  neurosis.  In  persons  who  practise 
masturbation  there  is  sometimes  a  large  quan- 
tity of  indiean  found  in  tlie  urine,  and  even  the 
emissions  of  these  persons,  wlien  dried  on  their 
linen,  show  spots  which  are  bordered  with  a 
marked  indigo  blue  or  violet  color.  After  ex- 
cesses in  venery,  as  after  sexual  excitement  in 
general,  we  find  large  quantities  of  indiean  in 
the  urine.  This  is  also  a  common  occurrence 
in  nervous  and  hysterical  women.  It  is  well 
known  that  in  diseases  of  the  central  nervous 
system,  especially  in  cerebro-spinal  meningitis, 
very  large  quantities  of  indiean  are  found  in  the 
urine  (Oppolzer).  Indiean  is  usually  present 
in  the  urine  in  solution,  yet  not  infrequently 
indigo  is  also  found  in  blue  and  bluish-black 
scales  and  flakes  in  the  urinary  sediment.  In 
the  nitric  acid  test  for  albumen  the  presence  of 
a  large  amount  of  indiean  is  shown  by  a  narrow 
blue  or  bluish  zone  resting  on  the  ring  of  brown 
coloring  matter  on  the  border  between  the  col- 
orless nitric  acid  and  the  urine.  If  this  bluish 
zone  is  distinctly  seen,  a  beautiful  separation 
of  indigo  may  be  obtained  by  the  Jaffe  test. 
Jaffe's  test  is  performed  in  the  following  man- 
ner :  about  ten  cubic  centimetres  of  urine  and 
an  equal  quantity  of  strong  hydrochloric  acid 
are  mixed  together,  and  to  the  mixture  are 
added  one   or   two  drops  of  a  cold  saturated 


20      Neuroses  of  the  Crenito-  Urinary  System 

solution  of  In'pochlorite  of  lime.  The  indigo 
immediutely  becomes  separated,  and  colors  the 
mixture  bluish-black  or  violet.  If  now,  accord- 
ing to  Senator,  a  few  cubic  centimetres  of  chloro- 
form are  added,  and  made  to  flow  through  the 
mixture  by  repeated  shaking  of  the  test-tube,  the 
chloroform  takes  up  the  indigo,  and  is  colored  a 
beautiful  blue.  It  is  well  known  that  indican 
appears  in  the  urine  in  large  quantities  in  dis- 
eases of  the  abdomen  (in  peritonitis,  constipa- 
tion, incarceration,  etc.).  I  have  seen,  in  a 
fatal  case  of  peritonitis  in  the  clinic  of  Prof. 
Lobel,  a  urine  colored  violet  by  the  large 
amount  of  indigo,  not  unlike  red  wine  in  ap- 
pearance and  with  a  deep-blue  sediment. 

Albumen  is  also  sometimes  found  in  these 
cases,  yet  relatively  seldom  and  only  in  small 
amount.  This  mild  albuminuria  is  ordinarily 
merely  transient,  and  is  only  found  after  great 
excitement,  just  as  it  occurs,  for  example,  after 
an  epileptic  fit.  Albuminuria,  indeed,  may  be 
produced  by  injury  to  the  floor  of  the  fourth 
ventricle,  and  Coe  even  maintains  that  the 
albuminuria  of  pregnancy  is  also  only  a  neu- 
rosis of  the  kidneys.  Still,  this  last  opinion  is  to 
be  accepted  with  great  caution,  since,  even  if 
this  explanation  be  the  right  one  in  cei-tain 
cases,  yet  it  certainly  does  not  hold  in  the 
majority  of  cases  of  albuminuria  of  pregnancy. 

The  urinary  sediment,  too,  in  the  neuroses  is 


in  the  Male.  21 

sometimes  very  characteristic.  Oxalate  of  lime 
is  very  often  found,  and  indeed  not  infrequent- 
ly in  large  quantities.  The  oxalate  of  lime  ap- 
pears in  the  form  of  colorless  crystals,  usually 
the  quadrate  octohedron  and  its  combiuation 
with  the  prism,  but  not  infrequently  the  diving- 
bell  or  hour-glass  forms  and  spheroids  of  oxalate 
of  lime  are  seen  mixed  with  the  octohedra  of 


Fig.  1.—  Oxalate  of  lime.    300  diameters. 

various  sizes.  I  have  seen  much  oftener  and 
much  greater  quantities  of  oxalate  of  lime  in 
the  urinary  sediment  of  cases  of  neurosis  than 
of  renal  calculi.  I  attribute,  therefore,  much 
less  importance,  in  the  formation  of  renal  cal- 
culi, to  the  oxalate  of  lime  than  to  the  sharp- 
pointed  uric  acid.     For  years  together  in  cases 


22     JYeuroses  of  the  Genito-  Urinary  System 

of  neurosis  I  have  seen  the  heaviest  sediment 
of  oxahite  of  lime  without  symptoms  of  begin- 
ning renal  calculus  appearing  at  the  same  time 

(Fig.  1). 

Another  not  uncommon  urinary  sediment, 
which  appears  only  as  a  result  of  a  neutral  or 
faintly  alkaline  reaction  of  the  urine,  consists  of 
amorphous  or  finely  granular  carbonate  of  lime 


Fig.  2.  —  Finely  granular  carbonate  of   lime   and  crystalline 
phosphate  of  lime.   300  diameters. 

mixed  with  amorphous  phosphate  of  lime.  The 
white,  finely  pulverized  sediment  is  dissolved 
on  the  addition  of  a  drop  of  acetic  acid,  with 
the  formation,  sometimes  of  few,  sometimes 
of  many,  bubbles  consisting  of  carbonic  acid. 
Sometimes  also,  mixed  with  the  amorphous 
sediment,  small,  colorless,  wedge-shaped  crystals 


in  the  Male.  23 

are  found,  the  bases  of  which  appear  bevelled ; 
these  consist  of  crystalline  phosphate  of  lime. 
The  crystals  appear  sometimes  single,  and  some- 
times so  grouped  together  that  several  crystals 
lie  side  by  side  with  their  apices  converging 
to  a  single  point.  Moreover,  whole  rosettes  or 
sheaves  are  seen,  of  which  the  bases  of  the  crys- 
tals form  the  periphery,  while  the  apices  unite 
at  the  middle  point  of  the  rosette  or  sheaf 
(Fig.  2).  A  rare  sediment,  sometimes  found 
mixed  with  the  crystalline  phosphate  of  lime,  is 
the  crystalline  phosphate  of  magnesia.  This  ap- 
pears usually  in  the  form  of  long  quadrilateral 
tablets,  of  which  the  opposite  corners  appear 
rounded  off.  All  these  forms  of  crystalline 
earthy  phosphates  are  also  found  in  the  urine 
after  the  ingestion  of  fixed  alkalies  or  of  min- 
eral waters  containing  such. 

Spermatozoa  are  likewise  not  uncommon  in  the 
urinary  sediment  of  men.  They  are  found  in 
large  numbers  in  the  urine  in  spermatorrhoea, 
yet  single  spermatozoa  appear  also  in  the  sedi- 
ment in  other  neuroses  of  the  urinary  system 
(Fig.  3). 

Finally,  as  already  mentioned,  indigo  in  small 
blue  or  bluish-black  scales  and  flakes  is  found 
in  the  urinary  sediment.  Sometimes  mdigo  is 
present  in  such  large  amount  that  the  sediment 
appears  blue.  This,  however,  is  a  very  rare 
occurrence.     In  one  case  of  tabes  and  paralysis 


24     Neuroses  of  the  Grenito-  Urmari/  System 

of  the  bladder  I  liave  had  the  opportunity  for 
a  long  time  of  observing  the  blue  sediment  of 
precipitated  indigo  ;  this  glaucuria  suddenly  dis- 
appeared. The  same  patient  suffered  also  with 
temporary  glycosuria  with  two  per  cent,  of 
sugar,  without  simultaneous  polyuria  or  other 
diabetic  symptoms.  If  at  the  same  time  urates, 
especially  urate  of  ammonia,  are  present  in  the 


Fig.  8. —  Amorphous  carbonate  of  lime,  crystalline  phosphate 
of  magnesia  and  spermatozoa.    300  diameters. 

urinary  sediment,  they  decompose  the  indigo, 
and  appear  sometimes  colored  blue,  sometimes 
violet  in  their  otherwise  characteristic  forms. 


The  Neuroses  of  the  Urinary  and  Sex- 
ual Organs  may  be  divided  into  three  well- 
recognized  groups,  according  as  they  affect  — 


in  the  Male.  26 

1.  Sensation. 

2.  Motion. 

3.  Secretion. 

Following  this  order,  the  neuroses  of  the 
urinary  apparatus  will  be  treated  first,  and  then 
those  of  the  sexual  organs. 

1.  (a)  The  Sensory  Neukoses  which  stand 
in  the  closest  relation  to  the  urinary  apimratus 
are  sometimes  confined  to  the  urethra  and  blad- 
der alone ;  sometimes,  however,  they  appear  also 
in  the  form  of  cutaneous  hypersesthesia  in  the 
vicinity  of  the  urinary  organs.  In  the  urethra 
the  patients  sometimes  feel  a  troublesome  burn- 
ing, which  is  especially  severe  in  the  pars  pen- 
dula  and  about  the  fossa  navicularis.  This 
burning  is  either  constant,  or  it  occurs  only 
during,  and  for  a  short  time  after,  micturition. 
At  times  the  patients  complain  of  an  increased 
sensitiveness,  of  a  feeling  of  rawness  of  the 
urethra  (Jiypercesthesia  urethrce).  Not  infre- 
quently, however,  the  sensitiveness  of  the  ure- 
thra increases  to  a  periodically  recurring  shoot- 
ing pain,  which,  according  to  the  account  of  the 
patients,  gives  rise  to  a  feeling  as  if  a  red-hot 
wire  had  been  pushed  into  the  urethra  from 
behind  toward  the  glans  penis  (neuralgia  ure- 
thrce). These  neuralgic  pains  often  come  on 
during  and  after  micturition ;  during  micturi- 
tion especially  when  the  penis  is  slightly  com- 
pressed with  the  fingers. 

2    B 


26     Neuroses  of  the  G-enito-JJrinary  System 

The  cutaneous  hypersesthesia  is  ordinarily 
confined  to  the  skin  of  the  penis  itself  and  that 
of  the  mons  veneris.  Yet  sometimes  patients 
complain  of  the  most  varied  sensations  in  the 
whole  abdominal  region,  in  the  nates  and  the 
thighs ;  now  a  burning,  stinging,  or  great  ten- 
derness of  the  skin,  again  a  feeling  of  numb- 
ness and  weakness.  In  some  patients  there  is 
at  the  same  time  an  increased  general  reflex 
irritability,  and  these  cases  often  present  symp- 
toms which  would  onl}^  be  looked  for,  in  such  a 
degree,  in  hysterical  women. 

As  to  cetiology,  the  patients  generally  ascribe 
their  trouble  to  a  gonorrhcea  which,  indeed,  has 
commonly  been  one  of  long  standing,  and 
accompanied  by  swelled  testicle  or  inflamma- 
tion of  the  bladder.  On  examination  of  the 
prostate  i^er  rectum  nothing  abnormal  is  felt. 

The  urine  shows  either  no  abnormal  condi- 
tion, or  it  contains  one  of  those  constituents 
which  have  just  been  described.  Thus  not  in- 
frequently the  earthy  phosphates  are  precip- 
itated by  heating.  At  the  same  time,  also,  it  is 
common  to  find  in  the  urine,  in  greater  or  less 
amount,  shreds  [Tripperfaden],  and  especially 
those  thick  and  short  ones,  sometimes  resem- 
bling large-headed  nails,  which  usually  come 
from  the  prostatic  urethra.  It  is  also  well 
known  that  in  the  various  diseases  of  the  pros- 
tate, hypersesthesia  or  neuralgia  of  the  urethra 


in  the  Male.  27 

occurs.  Thus  I  have  found,  at  least,  the  high- 
est degree  of  sensitiveness  of  the  penis,  and 
especially  of  the  glans,  in  patients  who  were 
affected  with  a  neoplasm  in  the  region  of  tlie 
prostate  and  neck  of  the  bladder.  On  examina- 
tion with  the  sound  a  greatly  increased  sensi- 
tiveness is  sometimes  met  with  in  the  prostatic 
urethra. 

Hypersesthesia  and  neuralgia  of  the  bladder 
are  common  accompaniments  of  spasm  of  the 
bladder,  and  will  be  treated  of  later  in  that  con- 
nection, among  the  motor  neuroses. 

All  these  neuroses  of  sensation,  occurring  in 
consequence  of  gonorrhoea,  are  generally  reflex 
neuroses,  and  readily  occur  in  connection  with 
catarrhal  prostatitis.  The  expulsion  of  numer- 
ous thick  and  short  shreds  with  the  very  begin- 
ning of  micturition,  and  the  absence  of  even 
the  least  secretion  from  the  urethra  (goutte 
militaire),  make  it  certain  that  the  diseased  por- 
tion of  the  urethra  is  in  the  region  of  the  exter- 
nal sphincter ;  consequently  in  a  place  which 
is  ordinarily  closed  by  muscular  action,  and  is 
only  opened  during  micturition.  Improvement 
therefore  ensues  forthwith  when  the  pars  pros- 
tatica  urethrse  and  the  prostate  itself  are  sub- 
jected to  local  treatment.  Next  to  warm  sitz 
baths  and  full  baths,  enemata  of  warm  water  or 
camomile  tea,  at  a  temperature  of  28°  Reaumur 
[95°  Fahr.],  twice  or  three  times  daily,  will  prove 


28     JV^euroses  of  the  Crenito-  Urinary  System 

most  efficient  in  connection  ■with  local  treatment 
of  the  prostatic  urethra.  This  latter  should  be 
so  carried  out  that,  by  means  of  instruments, 
astringents  and  even  nitrate  of  silver  are  intro- 
duced into  the  prostatic  urethra. 

I  usually  employ  in  the  local  treatment  of 
the  prostatic  urethra  a  short,  metallic  catheter 
(Fig.  4),  v^'hich  I  have  had  made  for  this  pur- 
pose. The  catheter  is  16  cm.  long,  and  has  a 
calibre  of  Charriere  No.  16.  The  vesical  end 
has  the  ordinary  curve  of  the  metallic  catheter, 
is  smoothl}'-  rounded,  and  is  perforated  like  a 
sieve.  The  outer  end  is  furnished  with  a  round 
plate  and  a  piece  of  rubber  tubing  (Fig.  4). 
The  catheter  is  introduced  to  such  a  depth  that 
its  point  is  just  within  the  membranous  portion 
of  the  urethra  (consequently  anterior  to  the 
prostate).  The  disk  prevents  the  catheter  from 
slipping  in  more  deepl}^,  and  at  the  same  time 
serves  to  close  the  external  meatus.  A  mark 
on  the  disk  shows  alwaj-s,  in  introducing  the 
catheter,  the  direction  of  the  vesical  end.  The 
catheter  having  been  in  this  manner  introduced 
into  the  membranous  urethra,  an  ordinarj'' 
syringe,  containing  100  grammes  of  fluid,  is 
attached  to  the  tubing  on  the  end  of  the  cathe- 
ter, the  latter  is  steadied  with  the  left  hand,  and 
the  whole  contents  of  the  syringe  is  slowly  and 
with  gentle  pressure  driven  through  the  pros- 
tatic urethra  into  the  bladder.     If  the  end  of 


in  the  Male. 


29 


;*■■ 


the  catheter  is  in  the  membranous  portion,  all 
the  fluid  can  be  injected  through  the  prostatic 
urethra  without  difficulty,  since  the  catheter  is 
already  partly  within  the 
external  sphincter,  which 
therefore  offers  no  resist- 
ance. If  the  point  of 
the  catheter,  however, 
reaches  only  the  bulbous 
portion,  then  the  fluid  can- 
not be  driven  through  the 
prostatic  portion  even  un- 
der strong  pressure ;  it 
will  either  flow  out  beside 
the  catheter,  or  will  pain- 
fully distend  the  urethra. 
These  injections  through 
the  prostatic  urethra 
should  be  given  once 
every  day,  or,  at  least, 
every  other  day.  For  the 
first  and  second  injection 
I  use  100  grammes  (a 
syringe  full)  of  a  1-4  to 
1-2  per  cent,  solution  of 
carbolic  acid,  then  I 
change  to  a  1-2  per  cent, 
[sulphate  of  ]  zinc  solu- 
tion ;  and,  as  soon  as  the 
patients   bear    the    injection    well,   I    increase 


■ii 

I}' 


«* 


V. 


•'*•*. 


Fig.  4,  —   Ultzmann'a 
Syringe-catheter. 


30     Neuroses  of  the  Geriito-  Urinary  System 

the  strength  gradually  to  a  3,  4,  and  5  per 
cent,  zinc  solution.  I  have  the  patients  empty 
the  bladder  before  and  after  each  injection. 
I  have  also  used  tannin  solutions  of  1-2,  1, 
and  2  per  cent.,  but  have  found  the  zinc 
solutions,  or  zinc  and  alum  together,  much 
more  efficient.  Similar  instruments  have  been 
used  before  for  the  same  purpose,  as  by  Guyon 
and  recently  by  Gross. 

The  patients  begin  to  feel  better  after  a  few 
injections,  and  later  they  urgently  crave  the 
injection  each  time.  Especially  excellent  is  the 
effect  of  the  injections  in  those  nervous  men 
who  behave  like  hysterical  women.  Thus  not 
infrequently  men  are  met  with  who,  after  a 
long-continued  gonorrhoea,  especially  when  com- 
plicated with  swelled  testicle  or  catarrh  of  the 
bladder,  become  moody  and  melancholy,  have 
no  desire  for  daily  work,  which  before  was  a 
necessity  for  them,  complain  of  a  feeling  of 
weakness  in  the  legs,  and  various  sensations  in 
the  hypogastric  region  and  the  genitals,  and 
suffer  at  the  same  time  with  frequent  and  pain- 
ful micturition,  emissions,  impotence,  and  other 
such  symptoms.  The  patients  immediately  be- 
gin to  improve  under  the  local  treatment  carried 
out  as  described.  After  a  few  injections  the 
lost  energy  returns,  the  patients  feel  their  trou- 
ble disappear,  and  become  again  gradually  in 
every  respect  capable  of  performing  their  func- 
tions. 


in  the  Male.  31 

(5)  The  sensory  neuroses  of  the  sexual  appar- 
atus are  confined,  now  to  a  sensitiveness  of  the 
testicle  and  spermatic  cord,  now  to  a  dragging 
and  stinging  sensation  in  the  testicle  (neuralgia 
testis'),  that  comes  on  periodically.  Sometimes 
there  is  a  painful  sensation  in  both  groins  or  a 
stinging  pain  in  the  urethra  during  and  after 
the  ejaculation  of  semen.  On  examination 
with  the  sound  the  urethra  is  found  sensitive 
throughout,  but  especially  in  the  prostatic  por- 
tion, where  the  pain  may  attain  such  a  degree 
that  the  patient  screams  aloud,  and  gnashes  his 
teeth. 

A  diminished  sensibility  of  the  urethra,  as 
also  of  the  skin  of  the  penis  and  scrotum,  is  not 
uncommon,  and  is  sometimes  met  with  in  an 
extreme  degree  in  that  form  of  impotence  which 
is  designated  as  nervous. 

By  impotentia  coeundi  is  meant  the  impossibi- 
lity of  consummating  the  normal  act  of  coition. 
The  explanation  of  this  condition  is  to  be  sought 
either  in  an  organic  change,  a  malformation,  a 
defect  of  the  penis,  or,  the  penis  being  healthy 
and  normally  formed,  in  the  inability  to  have  a 
lasting  and  powerful  erection.  In  the  first  case 
we  have  to  do  with  an  organic,  in  the  second 
with  a  nervous  or  psychical  impotence.  Cer- 
tain drags  may  cause  temporary  impotence,  and 
in  chronic  diseases  of  the  brain  and  spinal  cord, 
as  also  in  diabetes  mellitus,   even   permanent 


32     Neuroses  of  the  Crenito-  Uri7iary  System 

impotence  may  occur ;  that  form  of  impotence 
only  is  here  under  discussion  which  occurs  most 
frequently,  and  which,  as  already  mentioned,  is 
known  as  nervous  or  psychical  impotence. 

This  form  of  impotence  usually  occurs  in 
young  men,  and,  indeed,  in  those  who  either  suf- 
fer or  have  suffered  from  emissions  or  sperma- 
torrhoea, and  who  have  been  for  a  long  time 
addicted  to  masturbation.  This  form  of  im- 
potence may  be  relative,  or  it  may  hold  in  the 
same  degree  in  all  cases.  By  relative  impotence 
is  understood  the  inability  to  consummate  the 
sexual  act  with  certain  individuals,  while  with 
other  persons,  prostitutes,  for  instance,  it  suc- 
ceeds very  well.  This  state  of  things  occurs 
not  infrequently  among  married  people  who 
have  an  aversion  for  each  other.  In  one  case, 
in  which  the  wife  sued  for  divorce  on  account 
of  the  impotence  of  her  husband,  I  was  able  to 
convince  myself  that  the  husband  was  in  a  con- 
dition to  have  normal  sexual  intercourse  at  any 
time  with  other  persons.  Moreover,  it  is  com- 
monly the  case  in  nervous  impotence  that  the 
subjects,  when  they  are  alone,  and  give  them- 
selves up  to  lascivious  thoughts,  or  when  they 
awake  from  sleep  at  night,  have  powerful  and 
lasting  erections,  while  the  same  persons,  when 
it  comes  to  actual  intercourse,  can  get  no  erec- 
tion at  all.  It  also  not  infrequently  happens, 
that  when  in  coitus  there  is  an  erection  at  first, 


in  the  Male.  33 

it  is  too  weak  and  of  too  short  duration,  and 
the  ejaculation  of  semen  takes  place  too  soon, 
—  that  is,  ante  portas.  Sometimes  an  immissio 
penis  is  still  possible  when  the  vagina  is  large, 
but  the  penis  soon  becomes  completely  flaccid, 
and  no  emission  follows ;  the  coitus  is  incom- 
plete and  unsatisfactory. 

The  aetiology  of  this  form  of  impotence,  as 
already  mentioned,  is  to  be  found  in  masturba- 
tion and  other  unnatural  sexual  excesses.  The 
persons  affected  so  accustom  themselves  to  these 
extraordinary  means  of  sexual  gratification  that, 
when  they  attempt  normal  coitus,  they  are  no 
longer  successful.  Still  there  are  individuals 
who  have  been  guilty  of  little  or  no  sexual 
excess,  and  who  are  nevertheless  affected  with 
nervous  impotence.  These  are  either  persons 
who,  in  consequence  of  an  inherited  nervous 
predisposition,  and  as  a  result  of  exhausting 
mental  or  physical  exercise,  have  brought  their 
nervous  system  to  a  high  degree  of  tension, 
or  persons  who,  through  sudden  fright,  great 
pain,  etc.,  have  sustained  a  severe  shock  to  the 
nervous  system.  Thus  I  have  repeatedly  had 
patients  under  observation  who,  after  the  loss  of 
young  and  much-beloved  wives,  have  become 
suddenly  impotent,  although,  according  to  their 
own  account,  they  have  formerly  been  in  a  high 
degree  potent.  I  have  also  often  seen  tem- 
porary impotence  ensue  in  cases  of  great  loss 
of  money  and  property. 


34     Neuroses  of  the  Genito-Urinary  System 

This  form  of  impotence  can  best  be  explained 
by  considering  the  nature  and  origin  of  erec- 
tion. According  to  KoUiker  and  Kohlrausch, 
erections  are  brought  about  in  the  following 
manner  :  —  Under  the  influence  of  the  nervi  eri- 
crentes  the  organic  muscular  fibres  of  the  cav- 
ernous  tissue  become  relaxed,  and  the  inter- 
spaces thereby  enlarged  and  made  ready  for  the 
reception  of  a  large  amount  of  blood.  There 
is  still  a  second  factor  of  great  importance,  and 
that  is  the  prevention  of  the  back-flow  of  the 
blood  out  of  the  corpora  cavernosa.  This  dam- 
ming of  the  back-llow  is  probably  accomplished 
by  the  following  muscular  apparatus.  Along 
the  pars  subpubica  urethra  lies  the  musculus 
bulbo-cavernosus  which  begins  behind  in  a  ten- 
don from  which  also  the  musculi  transversi  per- 
insei  and  the  sphincter  ani  externus  take  their 
origin.  The  muscular  fibres  are  arranged  on 
either  side  like  the  plumes  of  a  pen,  and  pro- 
ject above  like  the  prongs  of  a  fork.  The  ends 
of  this  muscle  merge  in  a  thin  aponeurosis 
which  is  continuous  on  the  dorsum  of  the  penis 
with  the  tendons  of  the  musculi  ischio-caver- 
nosi  (Linhart).  When  this  muscular  apparatus 
contracts,  the  penis  in  the  region  of  the  sym- 
physis is  constricted,  and  the  return  of  blood 
prevented ;  at  the  same  time  also  (probablj 
through  the  influence  of  the  musculi  ischio- 
cavernosi)    the    penis    is    raised,    i.e.,  erected. 


in  the  Male.  35 

When  this  constriction  of  the  penis  by  mus- 
cular action  against  the  symphysis  is  incom- 
plete, and  on  that  account  the  erection  is  too 
feeble,  incomplete,  or  of  too  short  duration,  it 
is  well  known  that  voluptuaries,  in  order  to 
strengthen  this  muscular  action,  place  about 
the  root  of  the  penis  a  constricting  ring  of  rub- 
ber or  other  material. 

This  mechanism  of  erection  is  essentially 
under  the  influence  of  the  nervous  system. 
According  to  Eckhard,  erections  can  be  excited 
in  dogs  by  electrical  irritation  of  the  brain  as 
well  as  of  the  cord,  and,  indeed,  we  find  in  men 
also  that  libidinous  thoughts  as  well  as  certain 
diseases  of  the  central  nervous  system  have 
erections  as  a  result.  Peripheral  excitation  of 
the  genital  apparatus  also  causes  erections. 
Thus  it  is  commonly  found  that  with  a  full 
bladder  erections  occur  more  easily,  and  last 
longer  than  with  an  empty  bladder.  It  is  also 
well  known  that  during  the  night,  in  the  dorsal 
position,  the  pressure  of  a  full  bladder  on  the 
returning  blood-vessels  is  sufficient  to  excite 
powerful  erections.  We  know,  too,  that  inflam- 
matory irritation,  as  in  prostatitis  and  inflamma- 
tion of  the  seminal  vesicles,  serves  to  produce 
constant,  indeed  very  painful,  priapism.  And, 
finally,  it  is  well  known  that  peripheral  irritation 
applied  to  the  glans  penis,  the  skin  of  the  penis, 
and  the  testicles,  causes  erection. 


36     Xeuroses  of  the  Genito- Urinary  System 

Goltz  has  discovered  that,  for  the  excitation 
of  erection  through  peripheral  nerve-irritation 
in  dogs,  it  is  brought  about  more  promptly  and 
powerfully  when  the  lumbar  portion  is  divided 
from  the  rest  of  the  cord.  He  concludes  from 
this  that  the  influence  of  the  inliibitory  cerebral 
nerves  over  the  erection  is  thereby  eliminated. 

Nervous  or  psychical  impotence  may  there- 
fore be  dependent  on  the  increased  action  of 
the  inhibitory  nerves  brought  about  by  unpleas- 
ant, strongly  agitating,  excitement  of  the  brain. 
Through  the  action  of  these  inhibitory  nerves 
the  organic  muscular  fibres  of  the  corpora  cav- 
ernosa will  contract  and  oppose  an  obstacle  to 
the  entrance  of  the  blood  into  the  cavernous 
tissue.  Indeed,  patients  are  not  infrequently 
met  with  in  whom,  when  they  are  not  in  a  state 
of  sexual  excitement,  the  penis  is  shrivelled  and 
moves  itself  in  a  worm-like  manner,  which  might 
well  be  due  to  the  action  of  these  organic  mus- 
cular bands  in  the  corpora  cavernosa.  Exam- 
ination usually  shows  the  penis  of  such  per- 
sons to  be  small,  retracted,  and  with  the  skin 
wrinkled  on  the  dorsum. 

The  testicles  are  usually  normal,  indeed  some- 
times even  strongly  developed,  and  it  would 
certainly  be  a  mistake  to  draw  any  general  con- 
clusions as  to  increased  or  diminished  sexual 
power  from  the  size  and  consistence  of  the  tes- 
ticles, since  often,  as  is  well  knowm,  patients  in 


in  the  Male.  37 

whom  the  function  of  the  testicles  in  coition  is 
wholly  lost  through  obliteration  of  both  vasa 
deferentia  after  gonorrhoea!  epididymitis,  may 
yet  be  very  potent. 

The  skin  of  the  penis  is  frequently  found 
very  insensible  to  electrical  stimulation,  and 
there  is  also  commonly  a  very  different  degree 
of  irritability  of  the  skin  on  the  two  halves 
of  the  entire  genital  apparatus.  According  to 
Benedikt,  the  riglit  half  is  physiologically  more 
sensitive  than  the  left,  yet  I  have  not  infre- 
quently found  the  condition  reversed.  It  is 
also  common  to  find  that  the  before-mentioned 
muscular  arrangement,  which  acts  by  preventing 
the  return  flow  of  blood  from  tiie  corpora  cav- 
ernosa, reacts  only  feebly  to  electrical  stimula- 
tion. Since  this  is  the  same  muscular  apparatus 
which  throws  the  semen  out  of  the  urethra,  the 
declaration  of  patients  that  the  semen  during 
coitus  is  no  longer  thrown  out  as  powerfully  as 
formerly,  but  that  it  only  flows  out  sluggishly, 
is  explained.  If  in  healthy  men  a  rectal  elec- 
trode be  introduced  into  the  rectum,  and  an  ordi- 
nary sponge  electrode  as  the  second  pole  placed 
over  the  bulb  of  the  urethra  on  the  raphe  of  the 
perinseum,  such  powerful  contractions  of  this 
muscular  apparatus  can  be  brought  about  under 
normal  conditions  by  the  use  of  the  induced 
current  that  the  perinseum  bulges  out,  and  the 
hand  holding  the  electrode  feels  a  strong  im- 


38     Neuroses  of  the  Genito-  Urinary  System 

pulse.  Now  in  impotence  I  have  not  infre- 
quently found  that  these  contractions  of  the 
muscular  apparatus,  even  with  the  use  of  strong 
currents,  are  produced  only  incompletely,  and 
are  scarcely  perceptible. 

The  prognosis  in  psychical  or  nervous  im- 
potence is  usually  favorable.  Since  the  geni- 
tals are  otherwise  normally  formed  and  func- 
tionally capable ;  since  also,  usually,  powerful 
erections  occur,  although  always  at  the  wrong 
time ;  and  since  just  at  that  time  when  there  is 
a  strong  desire  for  an  erection  it  is  wanting,  so 
the  treatment  of  the  patient  must  be,  above  all, 
psychical.  The  influence  of  the  excited  cere- 
bral activity  over  the  inhibitory  nerves  of  erec- 
tion must  be  overcome,  then  the  patient  will 
again  be  potent.  Ordinarily  we  have  to  do 
with  abnormally  excitable,  so-called  nervous 
patients,  who  enter  upon  coitus  with  powerful 
erection,  but  extraordinary  excitement,  yet 
before  the  beginning  of  the  act  the  penis  has 
already  drooped,  and  its  introduction  becomes 
an  impossibility.  Such  a  failure  so  discourages 
the  patients  that,  if  it  is  repeated,  they  abstain 
from  any  further  trial  from  a  feeling  of  shame, 
and  regard  themselves  as  impotent.  In  such 
cases  the  comforting  advice  of  the  physician 
with  the  assurance  of  complete  cure  has  a  very 
quieting  effect  on  the  abnormally  excited  mind, 
and  not  infrequently  the  physician  sees  such 


in  the  Male.  39 

often  despairing  patients  depart  with  tears  in 
their  eyes  and  with  the  most  sincere  expressions 
of  gratitude. 

If  then  the  physician  has,  in  this  manner, 
won  the  confidence  of  his  patient,  the  latter 
also  is  much  more  composed,  and  the  further 
treatment  is  made  more  practicable.  Should 
evidences  of  strong  excitement  be  apparent 
notwithstanding,  bromide  of  potassium  might 
be  given  in  large  doses  (3  grammes  a  day),  or 
a  quieting  cold  water  cure  be  prescribed  with 
advantage. 

Local  treatment,  however,  is  always  the  most 
effectual.  This  may  be  either  electrical  or 
mechanical,  instrumental.  It  is  well  known 
that  through  the  application  of  irritants  in  the 
rectum  or  in  the  prostatic  portion  of  the  ure- 
thra erections  can  be  produced.  Thus,  after 
the  administering  of  enemata,  or  when  sounds 
are  allowed  to  remain  in  the  urethra,  very 
powerful  erections  not  infrequently  occur. 
The  object  of  treatment  must  be  to  make  it 
clear  to  the  patient  that  he  is  not  impotent,  and 
that  he  is  in  a  condition  to  have  lasting  and 
powerful  erections.  When  the  patient  has  once 
convinced  himself  of  this,  then  the  relief  of  his 
impotence  offers  no  further  difficulties.  The 
point  is  therefore  to  secure  to  the  patient  un- 
expected erections.  This  was  attained  by  Bene- 
dikt,  Schulz,  and  others  by  means  of  the  con- 


40     Neuroses  of  the  G-enito-Urinary  System 

stant  current  with  good  result.     Weak  currents 
were    usually  employed.     The    copper    pole    is 
placed  over  the  lumbar  vertebraj,  and  with  the 
zinc  pole   the   perinseum,  spermatic  cords,  and 
penis   are   successively   stroked.      Duration   of 
daily  sitting,  2  or  3  minutes ;  duration  of  treat- 
ment, 6  to  10  weeks.     In  obstinate  cases  Bene- 
dikt   employs   a   urethral    electrode    which   he 
unites  with  tlie  zinc  pole,  and  introduces  into 
the  prostatic  urethra.     This   proceeding,  how- 
ever, by  the  use  of  the  constant  current,  is  only 
a  galvanic  cauterization  of  the  pars  prostatica 
by  means  of  the  caustic  alkalies  of  the  tissues 
(caustic  soda?),  since,  according  to  electrical 
laws,  the  alkalies  are  set  free  at  the  zinc  pole. 
Although  these  methods  are  capable  of  produc- 
ing excellent  results,  yet  I  employ  the  faradic 
current,  following  the  experience  of  Duchenne, 
with  this  modification,  that  one  pole,  a  metallic 
staff  about  6  cm.  long,  is  placed  in  the  rectum. 
With  this  pole  in  the  rectum  the  other  electrode 
is  applied  successively  over  the  bulb  of  the  ure- 
thra, and  right  and  left  over  the  ascending  rami 
of  the  pubes.     In  this  manner  contractions  of 
the  musculus  bulbo-cavernosus  and  of  the  mus- 
culi  ischio-cavernosi  are  produced,  consequently 
of    that  muscular  apparatus  which  favors  the 
erection  of  the  penis,  and  promotes  the  ejacula- 
tion of  the  semen.     If  there  is  at  the  same  time 
anaesthesia  of  the  skin  of  the  penis  and  its  sur- 


m  the  Male.  41 

roundings,  or  if  diminished  sensibility  is  evi- 
dent, tlien  I  stroke  also,  occasionally,  these 
parts,  whereupon  the  normal  sensibility  directly 
returns.  This  method  of  treating  impotence  is 
not  infrequently  accompanied  by  the  most  ex- 
cellent results,  only  it  has  its  shady  side,  and 
that  is  that  nocturnal  emissions  are  promoted, 
i.e.,  increased.  When,  therefore,  frequent  pollu- 
tions are  at  the  same  time  present,  this  proced- 
ure is  not  especially  to  be  recommended,  since, 
to  use  a  simile,  we  should  only  be  stopping  one 
hole  with  another.  Fortunately,  however,  this 
form  of  impotence  is  rarely  complicated  with 
frequent  pollutions ;  much  oftener  with  sperma- 
torrhcea,  a  frequent,  sometimes  almost  contin- 
ual, flow  of  semen  without  accompanying  sexual 
excitement  and  erection.  But  when  spermator- 
rhoea is  present,  the  faradic  treatment  not  infre- 
quently works  so  far  favorably  that  it  changes 
the  almost  continual  flow  of  semen  into  a  per- 
iodical emission  with  erection  and  voluptuous 
sensation,  i.e.,  into  nocturnal  pollutions. 

The  local  treatment  by  means  of  bougies  or 
other  catheter-formed  instruments  is  likewise 
generally  successful  when  frequent  pollutions 
are  coexistent,  or  when  other  phenomena,  such 
as  neuroses  of  sensation  or  motion,  are  evident 
in  the  region  of  the  prostatic  urethra.  In  such 
cases,  which  are  wont  to  ensue  after  venereal 
excesses  of  high  degree,  or  which  are  engen- 


42     Neuroses  of  the  G-enito-Urinary  System 

dered  by  masturbation,  it  is  very  probable  that 
a  pathological  change  of  the  caput  gallinaginis 
is  involved.  This  form  of  impotence  must  con- 
sequently be  looked  upon  as  a  reflex  neurosis 
emanating  from  the  prostate,  and  is  to  be  treated 
accordingly.  There  are  also  those  obstinate 
cases  which,  according  to  Benedikt,  only  im- 
prove after  the  application  of  the  catheter-elec- 
trode. If  the  cause  of  the  neurosis  is  sought 
in  the  caput  gallinaginis,  then  the  local  treat- 
ment of  the  prostatic  urethra  is  at  least  the 
most  rational  procedure.  To  this  end  the  mild- 
est treatment  appears  to  be  the  introduction 
and  leaving-in  of  wax  or  flexible  rubber  bougies. 
More  powerful  is  the  action  of  thick  and  heavy 
metallic  sounds  which  stretch  the  urethra,  and 
exert  a  pressure  on  the  caput  gallinaginis.  In 
the  same  way,  also,  the  cold  sound  (psychro- 
phor  of  Winternitz)  works  very  advantageoush; 
while  here  to  metallic  pressure  cold  is  added. 
Should  all  these  means  be  of  no  avail,  then  a 
mild  cauterization  of  the  caput  gallinaginis 
with  nitrate  of  silver  might  be  tried.  All  these 
methods  will  be  treated  of  more  in  detail  under 
the  head  of  pollutions  and  spermatorrhoea. 

The  use  of  the  so-called  aphrodisiacs,  as  can- 
tharides,  phosphorus,  and  other  remedies,  I  con- 
sider harmful.  Just  as  injurious  I  regard  all 
apparatus  and  rubber  rings  which  are  placed 
about  the  root  of  the  penis  for  the  purpose  of 


m  the  Male.  43 

producing  more  powerful  and  lasting  erections. 
Tonics,  such  as  quinine  and  iron,  a  cold  water 
cure,  sea-bathing,  mountain  air,  are  useful,  and 
especially  to  be  recommended  as  after-treat- 
ment. 

2,  (a)  The  Motor  Neuroses  of  the  urinary 
and  genital  system  appear  sometimes  in  the 
form  of  spasmodic  contractions,  and  again  in 
the  form  of  paralysis.  In  the  urinary  system 
we  find  these  forms  best  defined  in  the  bladder, 
which  is  the  most  muscular  organ. 

In  the  urethra  these  phenomena  are  not  very 
distinctly  defined.  Yet  there  is  a  peculiar  con- 
dition which  might  be  attributed  to  spasm  of 
the  organic  muscular  fibres  of  the  urethra, 
which  sometimes  worries  patients  very  much, 
and  brings  them  to  the  physician,  namely,  the 
more  or  less  profuse  dribbling  of  urine  after 
micturition.  Tiie  patients  complain  to  the 
physician  that  after  they  have  completely  emp- 
tied the  bladder,  have  allowed  the  penis  to 
drain  off,  and  have  replaced  it  in  their  trousers, 
they  feel  suddenly,  on  taking  a  few  steps,  some- 
times a  few  drops,  and  again  a  larger  quantity 
of  urine  flow  from  the  penis,  and  sometimes  the 
trousers  are  wet  through  down  to  the  knee. 
This  phenomenon,  I  believe,  may  best  be  ex- 
plained by  supposing  this  small  quantity  of 
urine  to  have  remained  behind  in  the  urethra. 
The  retention  of   the  urine  in  the  urethra  is 


44     Neuroses  of  the  G-enito-Urinary  System 

favored  by  the  contraction  of  the  organic  mUvS- 
cuhu-  fibres  by  which  the  canal  is  narrowed,  and 
its  walls  made  more  resistant.  Now,  as  long  as 
this  contraction  of  the  organic  mnscnlar  fibres 
lasts,  the  urine  stands,  as  it  were,  in  a  tube  with 
rigid  walls.  It  can  no  more  flow  oat  than  a 
fluid  out  of  a  glass  tube  of  which  one  end  is 
closed.  As  soon  as  relaxation  of  these  organic 
muscular  fibres  ensues,  then  the  contents  of  the 
urethra  trickles  out,  just  as  a  fluid  out  of  a 
tube  with  thin  and  soft  walls,  as,  for  instance, 
a  gut  filled  with  water  with  one  end  tightly 
closed.  Tliis  so-called  dribbling  of  urine,  there- 
fore, should  be  attributed  to  a  spasmodic  con- 
traction of  the  organic  muscular  fibres  of  the 
urethra  throughout  its  whole  length. 

Much  more  important  and  noteworthy  is 
spasm  of  the  external  sphincter  of  the  bladder, 
the  spasmus  spliincteris  vesicce.  It  shows  itself 
in  this  way,  that  the  patients  complain  of  hav- 
ing a  frequent  impulse  to  urinate  ;  but  when 
the  call  comes  they  can  only  satisfy  it  with 
difficulty.  Sometimes  tliey  have  to  wait  and 
strain  five  or  ten  minutes  before  any  urine 
comes,  and  then  the  urine  does  not  flow  with 
its  normal  force,  but  at  first  by  drops,  then  in 
slight  spurts,  and  finally  in  a  full  stream.  At 
the  end  of  micturition  the  stream  again  be- 
comes thinner  until  the  urine  flows  only  by 
drops,  and  then   after  the  penis  has  been  re- 


in  the  Male.  4:5 

placed  in  the  trousers,  there  still  flows  a  small 
additional  quantity  of  urine.  They  also  com- 
plain that  they  are  often  entirely  unable  to  urin- 
ate, although  they  have  the  desire,  and  that  they 
have  to  depart  from  the  closet  without  having 
effected  their  purpose.  The  mildest  degree  of 
spasm  of  the  sphincter  is  the  phenomenon,  com- 
mon with  certain  persons,  mostly  very  nervous 
individuals,  of  not  being  able  to  urinate  in  the 
presence  of  a  second  person.  Sometimes  they 
cannot  pass  water  in  a  urinal  if  any  one  happens 
to  be  near.  This  spasmodic  contraction  of  the 
sphincter,  however,  is  not  always  of  so  harmless 
a  nature.  Sometimes  it  is  so  violent  as  to  lead 
to  retention  of  urine.  I  distinctly  remember  a 
case  in  which  micturition  was  each  time  only 
made  possible  by  the  injection  of  a  large  dose 
of  morphine.  The  patient  also  could  only  urin- 
ate in  a  sitting  position,  and  while  defecating. 
The  urethra  was  so  sensitive  that  examination 
with  the  sound  could  only  be  made  under  anaes- 
thesia; but  it  could  then  be  made  with  ease. 
Spasm  of  the  sphincter  of  the  bladder  has  been 
the  occasion  of  many  mistakes.  Since  there  is, 
in  fact,  an  obstacle  to  the  passage  of  urine, 
there  was  formerly  thought  to  be  either  disease 
of  the  prostate  or  a  stricture.  In  early  times, 
when  strictures  were  classified  in  the  broadest 
sense,  there  was,  besides  the  inflammatory  strict- 
ure, also  a  nervous  or  spasmodic  stricture.     Now 


46      Neuroses  of  the  Genito-  Uririary  System 

this  spasmodic  stricture  is  always  a  spasm  of 
the  external  sphincter  of  the  bladder.  The 
cause  of  this  spasmodic  stricture  is  generally  a 
diseased  condition  of  the  prostatic  portion  of 
the  urethra  or  of  the  prostate  itself.  The  fun- 
nel-shaped sphincter,  which  represents  the  pros- 
tatic and  membranous  portions  of  the  urethra, 
contracts  spasmodically  when  sources  of  irrita- 
tion have  localized  themselves  within  its  limits. 
We  find  as  an  analogue  spasm  of  the  sphincter 
ani  in  cases  of  catarrhal  ulceration  or  fissure, 
indeed  even  in  simple  inflammation  of  the  rec- 
tum ;  it  is  therefore  no  wonder  that  we  have 
spasm  of  the  sphincter  vesica?  with  similar  affec- 
tions at  the  neck  of  the  bladder,  especially  when 
reflex  spasm  of  the  sphincter  of  the  bladder  may 
be  brought  about  by  irritation  in  the  rectum. 
Such  irritation  localized  in  the  prostatic  urethra 
may  be  the  result  of  gonorrhoea  or  of  masturba- 
tion. Of  gonorrhoea,  when  a  prostatitis  catar- 
rhalis  gonorrhoica  is  present  and  we  find  its 
traces  in  the  thick-headed  shreds  contained  in 
the  urine.  Of  masturbation,  when  we  find,  on 
examination  with  the  sound,  that  the  prostatic 
urethra  is  very  sensitive,  and  bleeds  easily  with- 
out there  being  evidence  of  any  inflammation 
or  gonorrhoea ;  since  we  may  then  assume  that 
in  the  prostatic  urethra,  probably  about  the 
caput  gallinaginis,  hyper?esthesia,  hypersemia, 
even  a  catarrhal  condition  with  superficial  ero- 


in  the  Male.  47 

sion   of    the    mucous    membrane,   has   become 
localized. 

The  examination  with  the  sound  is  sometimes 
attended  with  great  difficulty,  and  demands  a 
practised  hand.  It  is  best  to  use  in  the  exami- 
nation a  cylindrical  metallic  sound  of  the  great- 
est possible  thickness  and  with  a  well-rounded 
point.  "With  soft  instruments  the  object  is  not 
attained,  for  they  become  bent  in  the  membran- 
ous portion.  Thin  instruments,  especially  small 
metallic  catheters,  never  serve  the  purpose  and 
are  absolutely  dangerous,  because  by  some  care- 
lessness they  may  easily  cause  injury  and  make 
false  passages.  Having  selected  a  suitable  met- 
allic sound,  it  is  passed,  held  as  lightly  as 
possible  between  the  thumb  and  forefinger, 
with  a  steady,  gradual  movement  down  to  the 
triangular  ligament.  Here  it  is  held,  and  the 
blunt  point  of  the  sound  is  pushed  gently  and 
firmly  against  the  isthmus.  After  waiting  a 
few  moments  the  contraction  of  the  sphincter 
is  gradually  felt  to  relax,  and  the  sound  can  be 
easily  passed  into  the  bladder.  If  the  catheteri- 
zation be  done  roughly,  and  the  sound,  arrived 
at  the  isthmus,  be  thrust  about  here  and  there, 
because  we  cannot  reach  the  bladder,  the  sphinc- 
ter is  only  stimulated  to  renewed  spasmodic  con- 
traction, and  the  instrument  cannot  be  made  to 
pass  through.  One  easily  explained  result  of 
this  difficult  catheterization  is  the  diagnosis  of 


48     Neuroses  of  the  Genito-  Urinary  System 

urethral  stricture  made  by  unskilful  physicians 
when  there  is  only  a  spasm  of  the  sphincter. 
We  also  find  in  literature  cases  reported  as  curi- 
osities, in  which  surgeons,  assuming  stricture  to 
be  present,  proceeded  to  do  external  urethrot- 
omy, and  then  to  their  great  astonishment  were 
able,  during  anaesthesia,  to  pass  very  large  in- 
struments into  the  bladder. 

The  treatment  must,  above  all,  be  directed  to 
making  the  sphincter  penetrable  for  catheter- 
formed  instruments.  This  is  best  accomplished 
by  the  daily  passing  of  large  metallic  sounds, 
allowing  them  to  remain  in  from  5  to  15  min- 
utes and  over.  This  practice  alone  is  ordinarily 
sufficient  to  establish  normal  micturition.  In 
certain  obstinate  cases,  however,  especially  when 
erosions  or  fissures  at  the  neck  of  the  bladder  are 
suspected,  the  prostatic  urethra  must  be  cauter- 
ized with  nitrate  of  silver  by  means  of  tlie  porte- 
remede. 

Much  more  frequent  is  the  true  spasm  of  the 
bladder,  cystospasmus^  which  is  accompanied  by 
vesical  tenesmus,  and  which  must  properly  be 
considered  as  a  spasm  of  the  detrusors  of  the 
bladder. 

The  spasmus  detrusorum  vesicce  occurs  in  dis- 
eases as  well  as  irritability  of  the  central  ner- 
vous system,  and  also  as  a  reflex  neurosis  in  ano- 
malies of  the  urethra,  especially  the  prostatic 
portion.     Frequent  micturition  is  common  with 


in  the  Male.  49 

strong  mental  emotions,  such  as  dread  and  fear, 
especially  in  such  individuals  as  are  of  a  con- 
genitally  nervous  temperament.  It  also  com- 
monly occurs  in  persons  who  by  overstrained 
pliysical  or  mental  activity  have  brought  their 
nerves  into  a  condition  of  exaggerated  excita- 
bility. We  likewise  find  vesical  tenesmus  after 
drinking  large  quantities  of  fluid,  especially 
when  it  acts  as  a  diuretic  on  account  of  the 
large  proportion  of  carbonates  or  of  free  car- 
bonic acid  contained  in  it.  It  is  not  infre- 
quently the  case,  also,  that  masturbation  and 
venereal  excesses  in  general,  through  which  un- 
natural erections  are  maintained  for  a  long  time, 
bring  about  hypersesthesia,  hypereemia,  and  mild 
catarrh  of  the  pars  prostatica,  and  especially 
of  the  caput  gallinaginis,  on  account  of  its  en- 
forced swelling ;  and  thence  arises  reflexly  in- 
creased contraction  of  the  detrusors.  It  is  well 
known  that  even  after  normal  coitus  one  is 
sometimes  constrained  to  urinate  more  often 
than  at  other  times.  Further,  we  find  not  in- 
frequently, after  a  gonorrhoea  which  has  run  its 
course  and  has  been  complicated  wdth  epididy- 
mitis and  prostatic  symptoms,  that  spasmus  de- 
trusor um  ensues.  Even  so,  sometimes  when 
the  urine  is  concentrated  and  rich  in  uric  acid, 
although  otherwise  normal.  Spasmus  detru- 
sorum   is   also   sometimes   excited   by  diseases 

of  the  rectum  (fissures,  catarrhal   ulcerations, 
3  c 


50      Neuroses  of  the  Genito-  Urinary  System 

etc.),  yet  under  these  circumstances  spasmus 
sphincteris  vesicas,  as  already  mentioned,  is 
much  more  frequently  found. 

Accordingly,  by  spasmus  detrusorum  we 
understand  a  frequent,  although  generally 
painless,  impulse  to  urinate.  This  impulse  to 
urinate  occurs,  for  the  most  part,  only  by  day, 
that  is,  when  physical  or  mental  activity  begins. 
In  the  night  there  is  usually  not  the  least  need 
felt  to  urinate,  so  long  as  the  patients  quietly 
sleep ;  when,  however,  they  pass  a  sleepless 
nisrht  the  vesical  tenesmus  is  all  the  stronger. 
Tlie  desire  comes  sometimes  hourly,  again  every 
10  or  15  minutes,  and  is  sometimes  so  violent 
that  when  the  patients  do  not  hasten  to  the 
closet  the  inline  flows  into  their  clothes  against 
their  will.  This  state  of  things  is  consequently 
just  the  opposite  to  that  described  in  the  case  of 
spasmus  sphincteris  vesicae. 

The  urine  is  usually  clear  and  of  a  pale  yel- 
low color.  It  has  a  low  specific  gravity  and  a 
neutral  or  faintly  acid  reaction.  There  is  simul- 
taneous polyuria  (urina  spastica,  nervosa).  Not 
infrequently  the  urine  is  turbid  and  alkaline 
without  there  being  any  sign  of  catan-h  of  the 
bladder,  and  without  any  alkali,  or  mineral 
water  containing  such,  having  been  taken  in- 
ternally. In  such  cases,  since  an  alkaline  and 
therefore  abnormal  urine  is  secreted  without 
evident    cause   in   the   kidneys,   we    must    as- 


in  the  Male.  51 

sume  a  perversion  of  the  normal  urinary  se- 
cretion, and  consider  this  urine  as  the  result 
of  a  coexisting  secretory  neurosis  of  the  kid- 
neys. If  the  urine  shows  with  litmus  paper 
a  neutral  or  faintly  acid  reaction,  we  find,  on 
heating,  that  turbidity  which  completely  dis- 
solves on  the  addition  of  a  drop  of  acetic  acid 
and  which  consists  of  neutral  earthly  phos- 
phates. The  demonstration  of  these  neutral 
earthly  phosphates  in  connection  with  the  neu- 
tral reaction  of  the  urine  essentially  supports 
the  diagnosis  of  neurosis  of  the  urinary  and 
sexual  system  in  general,  and  here  especially 
of  nervous  frequency  of  micturition,  cysto- 
spasmus.  We  also  find  sometimes  one  or  an- 
other abnormal  urinary  constituent  in  solu- 
tion or  in  the  urinary  sediment,  which  has  al- 
ready been  discussed  under  the  head  of  "  Urine 
in  Neuroses."  If  the  spasmus  detrusorum  has 
occurred  as  a  result  of  gonorrhoea,  we  find 
usually  those  short  and  thick-headed  shreds 
in  the  sediment  which  come  from  the  pros- 
tatic urethra. 

On  examination  with  the  sound  the  urethra 
and  bladder  are  found  very  sensitive,  the  pros- 
tatic portion  being  recognized  as  the  most  sensi- 
tive spot.  The  negative  result  of  the  examina- 
tion with  the  sound  and  the  normal  condition 
of  the  urine,  or  the  appearance  of  neutral  phos- 
phates   on   boiling,   together  with  the  neutral 


52      Neuroses  of  the  G-enito-  Urinary  System 

reaction  of  the  freshly  passed  urine,  establish 
the  diagnosis  of  cj'stospasnuis.  If  short,  thick 
shreds  are  also  visible  in  tlje  urine,  then  the 
opinion  gains  probability  that  \yq  have  to  do 
with  a  cystospasmus  which  has  come  about 
as  a  reflex  neurosis  from  the  pars  prostatica 
urethras. 

The  treatment  has,  in  this  case,  varied  condi- 
tions to  fulfil.  If  we  have  to  do  with  a  cysto- 
spasmus which  is  dependent  on  irritation  of  the 
central  nervous  system  this  harmful  influence 
must  first  of  all  be  wholly  removed.  Such  a 
patient  must  withdraw  himself  for  a  time  from 
overstraining  mental  occupation;  likewise  when 
sexual  excesses  have  been  the  cause  of  his  diffi- 
cult micturition,  or  when  other  harmful  influ- 
ences in  general,  such  as  pain  and  fear,  have  pro- 
duced a  permanent  effect.  In  such  cases  some- 
times a  pleasure  journey  does  excellent  service, 
and  sometimes  a  stay  in  the  country,  a  mild 
course  of  cold-water  cure,  sea  bathing,  or  warm 
baths  at  Romerbad,  Gastein,  Teplitz,  etc.  If  all 
these  things  are  impracticable,  agreeable  recrea- 
tion and  diversion  must  be  provided  for  as  much 
as  possible^  Of  internal  remedies,  bromide  of 
potassium  in  large  doses  (3  or  4  grammes  daily) 
works  best,  or  quinine,  iron,  and  arsenic  in  ordi- 
nary doses.  Morphine  or  some  other  narcotic  will 
temporarily  relieve  the  severe  vesical  tenesmus, 
and  is  best  given  in  the  form  of  a  sup[)ository. 


in  the  Male.  53 

If,  on  the  other  hand,  we  have  to  do  with  a  cysto- 
spasm  which  may  be  attributed  to  masturba- 
tion, venereal  excesses,  or  gonorrhoea,  then  the 
local  treatment  of  the  pars  prostatica  must  be 
undertaken.  In  such  cases  passing  sounds  is 
effectual,  or  treatment  with  astringents  by  means 
of  the  short  urethral  catheter  (as  described  on 
page  29),  in  connection  with  warm  clysters  and 
warm  baths. 

Among  the  motor  neuroses  of  the  urinary 
system,  and  especially  of  the  bladder,  which 
are  accompanied  by  diminished  power  of  con- 
traction, are  to  be  mentioned  paresis  and  paral- 
ysis of  the  sphincter  and  also  of  the  detrusors  of 
the  bladder.  Paresis  of  the  sphincter  is  fre- 
quently associated  with  incontinence  of  urine, 
and  paresis  of  the  detrusors  not  uncommonly 
with  retention  of  urine. 

By  paresis  of  the  bladder  is  to  be  understood 
the  inability  to  completely  empty  the  bladder. 
Paresis  of  the  detrusors  is  usually  meant  by 
this  expression.  A  tardy  evacuation  of  urine 
occurs  sometimes  in  otherwise  normal  men. 
Thus  I  have  several  times  observed  cases  in 
which  the  urine  was  evacuated  only  twice  in 
24  hours.  One  patient  in  particular,  a  strong 
young  man,  apparently  never  had  a  pressing 
desire  to  urinate,  and  said  that  he  urinated 
only  in  the  morning  and  evening,  and  then 
more   from   habit   than   from    a   desire   to   re- 


54     Neuroses  of  the  Genito-Urinary  System 

lieve  himself.  He  could,  so  he  said,  hold  out 
very  well  for  24  hours,  urinating  only  once. 
Once  when  he  came  to  me  he  declared  that  he 
had  not  passed  urine  for  20  hours.  I  had  him 
urinate  forthwith,  and  after  some  straining  and 
delay  he  passed  about  a  litre  of  normal  urine. 
The  bladder  was  distinctly  to  be  felt  over  the 
symphysis.  The  patient  complained  only  of  dif- 
ficult and  infrequent  urination  in  general.  I 
prescribed  mineral  waters  containing  soda  salts, 
massage  of  the  bladder,  cold  douches  on  the  lum- 
bar region  after  a  warm  bath,  and  micturition  at 
least  5  times  in  24  hours.  The  patient  must, 
whether  he  had  desire  or  not,  go  to  the  closet 
every  4  hours  and  pass  his  urine.  In  this  way 
the  patient  was  in  a  short  time  so  far  restored 
that  he  could  urinate  4  or  5  times  daily,  in  a 
normal  manner  and  without  straining. 

Paresis  of  the  detrusors  is  either  dependent 
upon  organic  change  of  the  muscular  fibres  (hy- 
pertrophy, fatty  and  amyloid  degeneration)  or 
it  is  a  question  of  motor  neurosis.  The  ina- 
bility to  completely  empty  the  bladder  is  best 
verified  by  having  the  patient  empty  his  blad- 
der as  much  as  possible  and  then  innnediately 
passing  a  catheter.  A  bladder,  to  be  normal, 
must  empt}''  itself  completely,  so  that  not  a 
drop  of  urine  can  be  obtained  with  a  catheter. 
If  the  spontaneous  emptying  of  the  bladder, 
however,  is  insufficient,  it  will  be  possible  always 


in  the  Male.  65 

to  evacuate  with  the  catheter  a  greater  or  less 
quantity  of  urine.  The  amount  of  urine  thus 
evacuated  will  be  a  measure  of  the  insufficiency 
of  the  bladder.  The  more  residual  urine  there 
is  to  be  drawn  with  the  catheter,  the  weaker 
usually  are  the  detrusors  of  the  bladder.  I  say 
usually,  because  there  are  cases  in  which  the  eva- 
cuation of  urine  is  insufficient  on  account  of  some 
mechanical  obstruction.  Such  obstructions  are 
generally  strictures  of  the  urethra,  chronic  pros- 
tatitis, and  hypertrophy  of  the  prostate.  In  such 
cases,  hypertrophy  of  the  muscular  coat  of  the 
bladder  is  also  found  as  a  complication.  If,  how- 
ever, there  is  no  such  mechanical  obstruction  to 
the  passage  of  urine,  we  have  as  a  rule  to  do 
with  paresis  or  paralysis  of  the  detrusors. 

The  patients  usually  complain  that  they 
urinate  very  badly.  Before  each  act  of  mic- 
turition, which  is  indeed  painless,  they  have 
to  wait  a  long  time,  pressing  and  straining, 
until  the  urine  comes,  and  even  when  it  comes 
it  does  not  flow  in  a  bow-like  stream,  but  falls 
without  force  perpendicularly  from  the  urethra, 
just  as  rain-water  trickles  from  the  roof.  While 
lying  down  they  cannot  urinate  at  all,  and  stand- 
ing the  urine  flows  best  if  they  lean  forward 
and  press  on  the  abdomen.  The  more  incomplete 
the  evacuation  of  urine  is,  the  oftener  comes  the 
desire  to  urinate,  yet  there  is  never  a  feeling  of 
satisfaction  after  urinating.     If  the  paresis  pass 


56      I^euroses  of  the  G-enito-  Urinary  System 

gradually  into  paralysis,  incontinence  occurs  at 
first  during  tlie  night,  and  after  some  time  grad- 
ually becomes  constant.  The  patients  have  a 
feeling  of  fulness  in  the  hypogastriuni,  they 
urinate  very  often,  and  each  time  only  a  small 
quantity  of  urine  is  passed  by  resorting  to  ab- 
dominal pressure ;  yet  the  urine  still  flows  con- 
stantly by  drops.  They  never  again  have  the 
feeling  of  satisfaction  after  urination. 

Paralysis  of  the  bladder  is  generally  found  in 
chronic  cerebral  and  spinal  diseases.  Yet  it 
occurs  also  in  the  various  acute  febrile  pro- 
cesses when  they  are  complicated  with  affections 
of  the  central  nervous  system,  but  it  is  then 
for  the  most  part  temporary.  In  advanced  age 
insufficiency  of  the  evacuation  of  urine  occurs 
almost  as  a  rule,  although  well-pronounced  par- 
esis is  not  always  apparent.  In  youth  and  in 
vigorous  middle  life  a  paretic  condition  of  the 
bladder,  especially  of  the  detrusors,  occurs  in 
such  individuals  as  have  retained  their  urine  for 
a  long  time,  or  in  such  as  suffer  from  spastic 
contractions  of  the  vesical  sphincter  as  a  result 
of  venereal  excesses  or  of  masturbation.  That, 
in  cases  of  prostatic  enlargement  and  of  strict- 
ure, or  other  permanent  obstructions  to  the  eva- 
cuation of  urine,  hj^pertrophy  in  the  beginning 
and  later  paresis  of  the  detrusors  of  the  bladder 
becomes  established,  has  been  already  men- 
tioned. 


in  the  Male.  57 

Sometimes,  in  certain  clinical  cases,  we  can 
recognize  very  well  the  two  following  forms  of 
paresis  and  paralysis  of  the  bladder,  namely, 
on  the  one  hand  when  the  sphincter,  and  on 
the  other  when  the  detrusors,  are  paralyzed. 
In  paralysis  of  the  detrusors  incontinence  is 
usually  found  only  in  the  more  advanced  stages ; 
for,  since  the  sphincter  is  closed,  the  urine  first 
begins  to  dribble  only  after  the  bladder  has  be- 
come distended  to  the  maximum,  just  as  a  ves- 
sel filled  to  the  brim  must  overflow  when  still 
more  fluid  flows  in.  In  paresis  of  the  sphinc- 
ter, on  the  contrary,  we  have  incontinence  very 
early,  because  the  closure  of  the  bladder  has 
become  defective.  Incontinence  in  this  case 
begins  usually  by  day,  because  in  the  erect 
position  of  the  patient  the  weak  sphincter  is 
much  more  easily  overcome  by  the  volume  of 
urine  pressing  on  it  from  above,  than  while 
lying  in  bed.  Further,  in  paresis  of  the  detru- 
sors retention  of  urine  sometimes  takes  place, 
which  does  not  occur  in  paresis  of  the  sphinc- 
ter. If,  namely,  a  great  volume  of  urine  col- 
lects in  the  bladder,  as  can  only  happen  in  par- 
esis of  the  detrusors,  it  thus  forms  a  heavy  mass 
wliich  obstructs  the  circulation  of  blood  in  the 
prostate  and  about  the  neck  of  the  bladder  in 
general.  Hence  ensues  an  oedematous  swelling 
of  the  prostate  and  retention  of  urine  is  brought 
about. 

3* 


58      JVeuroses  of  the  Genito-  Urinary  System 

Oil  examination  of  the  patient  the  differential 
diagnosis  is  sometimes  much  easier  still  to  estab- 
lish. If  the  detrusors  alone  are  paretic,  and  the 
sphincter  still  works  efficiently,  the  bladder  is 
found  distended,  as  a  fluctuating  tumor  over  the 
symphysis,  or  else  a  flaccid  bag  filled  with  fluid 
is  felt,  which,  being  compressed  with  the  hand, 
causes  a  desire  to  urinate.  It  is  also  possible, 
in  spite  of  the  2)atient's  declaration  that  he  has 
just  urinated,  to  demonstrate  by  percussion  sev- 
eral finger-breadths  of  dulness  over  the  sj^m- 
physis.  In  paresis  of  the  sphincter  the  spherical 
form  of  the  distended  bladder  is  never  felt  over 
the  symphysis.  The  sphincter  is  to  such  a 
degree  weakened  that  it  is  not  in  a  condition  to 
offer  resistance  to  a  large  accumulation  of  urine 
in  the  bladder;  the  urine  flows  away  involun- 
tarily. Consequently  large  quantities  of  urine 
are  veiy  seldom  found  ;  indeed,  in  some  cases 
it  is  impossible  to  show  over  the  symphysis  any 
distention  of  the  bladder  with  accumulated 
urine.  If  we  pass  a  catheter  into  the  bladder, 
we  usually  meet,  in  paresis  of  the  detrusors,  a 
powerful  resistance  at  the  neck  of  the  bladder, 
whereas  in  paresis  of  the  sphincter,  meeting  no 
resistance,  we  almost  fall  with  the  instrument, 
figuratively  speaking,  into  the  bladder.  If  the 
urine  be  drawn  off,  a  larger  quantity  will  usu- 
ally be  found  in  paresis  of  the  detrusors  than  in 
paresis  of  the  sphincter.     Yet  not  infrequently 


in  the  Male.  59 

paresis  of  the  detrusors  is  complicated  with  par- 
esis of  the  sphincter,  so  that  these  typical  phe- 
nomena are  no  longer  capable  of  demonstration. 
When  the  urine  flows  through  the  catheter,  the 
patient  being  in  the  horizontal  -position,  we 
notice  at  the  beginning  of  the  flow  a  relatively 
powerful  stream;  soon,  however,  it  diminishes, 
and  the  urine  flows  down  perpendicularly  and 
in  a  weak  stream  from  the  end  of  the  catheter. 
Only  by  the  impulse  of  coughing  or  by  pressure 
on  the  belly  is  a  more  powerful  and  bow-formed 
stream  caused,  which,  however,  immediately  be- 
comes weak  and  powerless  again.  Finally  the 
urine  stops  flowing  entirely,  yet  if  we  press 
with  the  flat  of  the  hand  on  the  fundus  of  the 
bladder,  or  have  the  patient  get  up  and  grad- 
ually assume  the  upright  position,  then  the 
urine  still  flows  from  the  bladder  in  greater  or 
less  amount. 

The  urine  is  either  normal,  or  it  shows  a  neu- 
tral or  faintly  alkaline  reaction,  with  a  precipi- 
tate of  neutral  earthy  phosphates.  Sometimes 
the  urine  has  been  from  birth  turbid  and  alka- 
line, without  there  being  an  accompanying 
catarrh  of  the  bladder.  The  turbidity  and  the 
whitish  sediment  consist  merely  of  earthy 
phosphates.  In  the  sediment  are  found  either 
the  amorphous  or  the  granular  carbonate  of 
lime,  the  crystalline  phosphate  of  lime,  and 
sometimes  even  phosphate    of   magnesia    crys- 


60     JVeuroses  of  the  Crenito-Urinary  System 

tallizing  in  long,  rectangular  plates.  Occa- 
sionally I  have  also  found  sugar,  to  the  amount 
of  2  per  cent.,  in  paresis  of  the  bladder,  without 
there  being  in  addition  any  of  the  general  symp- 
toms of  diabetes.  The  sugar,  moreover,  after 
being  present  months  and  years  long,  has  sub- 
sequently disappeared  completely  from  the  urine 
without  anything  having  been  done  for  the 
glycosuria.  If,  however,  the  stagnation  of  urine 
in  the  bladder  continues  for  a  long  time,  a 
j^urulent  catarrh  of  the  bladder  or  a  purulent 
cystopyelitis  gradually  comes  about,  and  in  the 
urine  as  well  as  in  the  sediment  are  found  the 
characteristic  evidences  of  these  affections,  such 
as  albumen  and  carbonate  of  ammonia  in  solu- 
tion, and  in  the  sediment  pus  corpuscles,  crys- 
tals of  ammonio-magnesic  phosphate,  bladder 
and  renal  epithelium.  This  purulent  catarrh 
of  the  bladder  occurs  very  easily  when  the 
bladder  has  been  previously  examined  with  a 
sound  or  other  catheter-formed  instrument. 

The  prognosis  in  paralysis  of  the  bladder  is 
not  very  favorable,  and  in  most  cases  the  urine 
must  thenceforth  be  constantly  drawn  with 
the  catheter.  This  must  be  explained  to  the 
patients,  else  they  will  unnecessarily  blame  the 
physician  for  having,  by  catherization,  reduced 
them  to  such  a  condition  that  they  are  no  longer 
able  to  pass  their  water  spontaneously,  as  was 
still  possible,  they  say,  before  the  use  of  the 


in  the  Male.  61 

catheter.  The  greater  the  amount  of  urine 
which  can  be  drawn  from  the  bladder  with  the 
catheter,  the  more  unfavorable  is  also,  usually, 
the  prognosis,  as  regards  the  contractility  of  the 
bladder.  During  the  subsequent  catheteriza- 
tion, also,  inflammatory  processes  are  not  infre- 
quently set  up  in  the  urinary  tract,  which  may 
even  be  capable  of  immediately  threatening  the 
life  of  the  patient. 

The  older  expressions  which  were  formerly 
used  in  connection  with  the  motor  neuroses  of 
the  bladder,  such  as  incontinentia  urinee,  stran- 
gury, and  ischuria,  I  have  not  here  made  use  of, 
since  they  are  only  general  diagnostic  terms, 
and  are  often  used  in  entirely  different  morbid 
conditions.  Nevertheless  the  etymology  of  these 
expressions,  which  are  still  sometimes  employed, 
should  be  briefly  reviewed.  By  iyicontinentia 
urince  (from  in  privative  and  contineo,  to  hold 
together,  hold  fast)  is  understood  the  inability 
to  hold  back  the  urine.  That  this  condition 
may  occur  in  the  most  varying  affections  of  the 
urinary  apparatus,  is  clear.  By  strangury  (from 
TO  ovpov,  the  urine,  and  srpayycu,  I  press,  urge, 
strain)  is  understood  a  straining  at  micturition, 
when  the  urine  comes  only  by  drops  and  with 
great  pain.  Finally,  we  understand  by  ischuria 
(from  tsx'^j  ^o  hold,  hold  back,  and  ovpov 
urine)  retention  of  urine  or  sometimes  very 
difficult  micturition. 


62     Neuroses  of  the  Genito-Urinary  System 

The  treatment  of  paresis  of  tlie  bladder  may 
be  very  varied.  In  light  cases  where,  in  strong 
persons,  mostly  from  a  bad  habit,  a  slow  and 
infrequent  micturition  has  become  established, 
daily  massage  of  the  bladder,  in  connection 
with  regular  micturition  at  short  intervals  and 
with  mild  diuretics,  such  as  mineral  waters  con- 
taining soda  salts,  will  be  sufficient.  Gymnas- 
tics, a  visit  to  the  country  or  mountains,  cold 
rubbing  of  the  whole  body,  cold  sitz-baths, 
douching  of  the  perinseum,  over  the  bladder 
and  the  lumbar  region ;  further,  showering  the 
back  with  cold  water  immediately  after  coming 
out  of  a  hot  bath,  all  work  very  advantageously 
in  stimulating  the  contractility  of  the  bladder. 
Of  internal  remedies,  quinine,  ergot,  and  strych- 
nia are  given  with  good  effect.  Of  quinine 
and  ergot  0.5  gramme  daily  may  be  given,  and 
strychnia  either  internally  (strycli.  sulph.  0.02, 
sacch.  albi  3.00,  div.  in  dos.  no.  vi ;  1  or  2  pow- 
ders daily)  ;  or  endermically  (strych.  nitr.  0.10, 
sacch.  albi  5.00,  div.  in  dos.  no.  x),  the  mons 
veneris  being  shaved,  the  epidermis  being  re- 
moved by  means  of  a  blister,  and  every  day 
a  powder  dusted  on  the  denuded  corium;  or 
hypodermically  (strych.  nitr.  0.05,  aq.  dest. 
10.00 ;  one  half  to  a  whole  Pravaz  syringeful 
daily),  which  offers  the  most  convenient  and 
the  best  means  of  employing  strychnia.  It  is 
best  to  inject  it  into  the  skin  of  the  abdomen  over 


in  the  Male.  63 

the  bladder.  As  soon  as  muscular  twitching  or 
general  symptoms  of  exalted  muscular  excit- 
ability are  apparent,  this  remedy  must  be  dis- 
continued. 

Electricity  may  be  used ;  one  pole,  as  a  cathe- 
ter-formed electrode,  being  passed  into  the  blad- 
der, and  the  other  pole  placed  over  the  lumbar 
vertebrae,  or  introduced  into  the  rectum.  The 
constant  as  well  as  the  induced  current  may  be 
employed.  I  can  recommend  the  use  of  elec- 
tricity by  means  of  the  catheter-formed  elec- 
trode only  for  a  later  period  of  the  treatment, 
indeed,  not  until  regular  catheterization  has 
been  practised  for  weeks  and  months.  Just  in 
the  beginning  of  treatment,  stimulation  of  the 
bladder  often  acts  very  harmfully,  for  the  reason 
that  it  is  too  irritating  for  the  mucous  mem- 
brane, and  sets  up  a  purulent  catarrh  of  the 
bladder.  Later  in  the  course  of  treatment, 
however,  if  there  is  not  at  the  same  time  puru- 
lent pyelitis  or  nephritis,  this  method  of  using 
electricity  often  shows  good  results.  In  paresis 
of  the  detrusors  there  is  to  be  recommended  the 
introduction  of  a  catheter-formed  electrode  into 
the  bladder,  the  other  pole  being  placed  over 
the  lumbar  vertebrae,  while  in  paresis  of  the 
sphincter,  or  when  this  predominates,  the  same 
electrode  is  only  to  be  passed  into  the  pars 
prostatica  urethrse.  The  sphincter  vesicae  can 
also  be  made  to   contract  by  faradization   per 


64     Neuroses  of  the  G-enito-  Urinary  System 

rectum^  without  the  need  of  first  passing  a 
pole  into  the  urethra,  which  will  be  discussed 
more  fully  in  connection  with  enuresis.  This 
method  is  especially  indicated  for  very  sensitive 
patients. 

The  best  treatment,  however,  is  always  a 
thoroughly  carried  out,  regular  course  of  cathe- 
terization, and  an  advanced  case  of  this  kind 
can  scarcely  ever  be  treated  with  a  favorable 
result  without  catheterization.  Since  the  cathe- 
terization should  be  as  gentle,  and  cause  as  little 
irritation  as  possible,  in  paresis  and  paralysis  of 
the  bladder,  whenever  practicable,  and  especially 
in  the  beginning  of  treatment,  only  catheters  of 
vulcanized  rubber,  the  so-called  Nelaton  cathe- 
ters, should  be  used,  such  as,  manufactured  from 
most  excellent  material  (Jaques'  patent),  are 
now  imported  from  England.  A  paretic  blad- 
der cannot  completely  empty  itself,  and  we 
must  therefore,  by  regular  catheterization,  force 
it  to  gradually  contract  while  we  draw  off  its 
contents. 

The  use  of  the  catheter  in  paresis  of  the 
bladder  is  usually  attended  with  no  further  dif- 
ficulty. The  patient  very  soon  learns  the  man- 
agement of  it  himself,  and  in  cases  running 
a  favorable  course  it  will  become  possible  to 
gradually  diminish  the  catheterization,  indeed 
even  to  discontinue  it  altogether.  Not  so,  how- 
ever, in  cases  running  an   unfavorable   course. 


in  the  Male.  65 

Here  not  infrequently  purulent  catarrh  ensues, 
and  parenchymatous  processes  of  the  bladder 
and  kidneys,  with  abscess  formation,  and  it 
goes  on  sometimes  wholly  unexpectedly  and  in 
a  short  time  to  a  fatal  issue. 

The  conditions  of  pressure  within  the  urin- 
ary apparatus,  and  especially  within  the  bladder, 
exert,  not  infrequently,  the  greatest  influence 
on  the  success  or  failure  of  operative  treatment. 
Instruments  may  usually  be  introduced  with 
impunity  into  a  bladder  which  possesses  full 
capability  of  contraction,  and  catheters  may 
even  be  allowed  to  remain  in  a  considerable 
time ;  yet  when  the  contractility  of  the  bladder 
is  weakened,  and  the  pressure  in  it  is  conse- 
quently negative,  sometimes  the  stormiest  and 
most  dangerous  complications  ensue  on  ordinary 
catheterization.  I  have  several  times  seen,  even 
with  a  slight  degree  of  j^aresis  of  the  bladder, 
cystopyelitis  and  pyelonephritis,  with  violent 
febrile  symptoms,  follow  on  the  first  evacuating 
catheterization.  And  in  every  case  of  paresis 
and  paralysis  of  the  bladder  a  reaction,  with  in- 
flammatory symptoms  in  the  urinary  organs,  is 
so  associated  with  catheterization  that  the  treat- 
ment of  this  bladder  affection  in  patients  up  and 
about  becomes  impossible.  The  patients  always 
feel  very  much  relieved  after  the  first  catheter- 
ization, and  cannot  thank  the  physician  enough 
for  using  the  catheter ;  the  second  day  also  is 


66     Neurones  of  the  G-enito-Urinary  System 

passed  in  good  health.  With  the  third  day, 
however,  they  begin  to  complain  of  depression 
and  lassitude,  the  urine  becomes  turbid,  the 
temperature  rises,  and  on  the  fifth  or  sixth  day 
after  the  first  catheterization  comes  the  first 
severe  chill,  which  renders  the  patient  wholly 
unable  to  leave  his  bed.  That  the  more  insuf- 
ficient a  bladder  is,  and  the  greater  the  quantity 
of  urine  is  which  must  be  drawn  off  with  the 
catheter,  so  much  the  more  severe  is  the  sub- 
sequent reaction,  is  easily  understood.  There 
are  cases  recorded  in  literature  where  in  paresis 
of  the  bladder  the  evacuating  catheterization 
was  undertaken  with  the  patient  standing  erect, 
and  where  the  patient,  after  a  large  quantity  of 
urine  had  been  drawn  off,  at  the  end  of  the 
catheterization  suddenly  fell  dead.  It  is  there- 
fore advised  always  to  pass  the  catheter  in  the 
horizontal  position.  Not  rare  also  are  cases  in 
which,  with  the  first  catheterization,  a  perfectly 
normal  urine  is  evacuated,  the  patient  looking, 
moreover,  healthy  and  strong,  and  in  which, 
after  an  interval  of  8  to  10  daj'-s,  the  same 
patient  perishes  with  ursemic  symptoms.  In 
these  cases,  to  the  purulent  cystopyelitis  an 
acute,  usually  suppurative,  nephritis  is  added. 
There  are  also  cases  in  which  after  the  third 
day  of  catheterization,  the  urine  begins  to  grow 
bloody.  The  bleeding  is  usually  parenchym- 
atous,   coagula    are    not    present,   yet    it    can 


in  the  Male.  67 

be  demonstrated  microscopically,  by  the  evi- 
dence of  hgemorrhagic  renal  epithelium  and  of 
so-called  blood  casts,  that  not  alone  the  blad- 
der, but  the  whole  urinary  tract  bleeds.  The 
urine  has  now  a  red,  now  a  brown  or  black 
color  ;  later,  after  a  purulent  catarrh  of  the 
bladder  has  also  developed,  the  color  of  the 
urine  becomes  brownish  green,  the  reaction 
strongly  alkaline,  and  the  odor  strong  of  de- 
composition. We  have  to  do,  then,  in  a  word, 
with  an  ichorous  hseraorrhagic  cystitis  or  cysto- 
pyelitis  with  or  without  suppurative  nephritis. 
Sometimes  it  is  observed,  when  the  sediment  is 
thoroughly  examined  with  the  microscope,  that 
a  growth  of  bacteria  is  rapidly  progressing. 
Not  only  are  single,  small,  two  and  four  limbed 
bacteria  seen  in  vigorous  motion,  but  whole 
clumps  and  shreds  are  brought  to  view  by  tlie 
microscope  which  consist  of  motionless  bacteria 
massed  together.  These  collections  of  bacteria, 
when  from  the  bladder,  appear  in  large,  irreg- 
ular, membranous  masses ;  but  if  they  have 
been  compressed  in  the  kidneys,  they  tightly 
plug  the  tubules,  and  when  such  plugs  of  bac- 
teria pass  off  with  the  urine,  they  appear  under 
the  microscope  as  beautiful  cylindrical  casts, 
which  consist  entirely  of  motionless  bacteria 
{Nephritis  parasitica  of  Klebs).  The  prognosis 
in  nephritis  suppurativa  is  almost  always,  in 
these  cases,  unfavorable. 


68     Neuroses  of  the  Crenito-Urinary  Sijstem 

There  are  yet  other  cases,  in  which  the  neph- 
ritis suppurativa  has  not  involved  the  whole 
kidney,  and  in  the  conrse  of  a  few  weeks  com- 
parative health  is  established;  this  process, 
however,  is  gradually  associated  with  an  inter- 
stitial nephritis,  to  kill  the  patient  with  all  the 
more  certainty  after  an  interval  of  2  or  3  years. 

Very  often  we  see  parenchymatous  processes 
in  the  urinary  organs  set  in  after  catheteriza- 
tion. The  patients  are  usually  confined  to  the 
bed,  and  are  feverish.  The  urine  is  relatively 
only  slightly  clouded  v^ith  muco-pus,  and  con- 
tains only  correspondingly  little  albumen.  Sud- 
denly comes  a  chill  that  is  soon  followed  by  a 
second  and  a  third,  and  at  last,  after  the  evacua- 
tion of  a  large  amount  of  pus  with  the  urine, 
there  is  improvement.  Yet  this  improvement 
lasts  only  a  short  time,  for  soon  the  chills  begin 
anew,  again  to  give  way  to  improvement  after 
repeated  evacuations  of  pus.  This  play  of  im- 
provement and  exacerbation  may  last  weeks  and 
months,  until  finally  permanent  improvement 
ensues,  or  until  the  patient  perishes.  Still  there 
remains  in  the  urine  constant  evidence  of  cysto- 
pyelitis,  which,  although  late,  passes  gradually 
into  a  nephritis. 

The  cause  of  these  unpleasant  complications 
of  paresis  of  the  bladder  after  catheterization  is 
to  be  sought  in  the  negative  conditions  of  pres- 
sure within  the  urinary  apparatus.     In  paresis 


in  the  Male.  69 

and  paralysis  of  the  bladder,  this  organ  can 
never  be  completely  emptied  spontaneously ; 
there  remains  always  in  the  bladder  a  greater 
or  smaller  residuum  of  urine.  This  residuum 
of  urine,  usually  increasing  year  by  year,  exerts 
by  its  volume  a  certain  lateral  pressure  on  the 
walls  of  the  bladder.  Likewise,  on  account  of 
this  residuum  in  the  bladder,  is  the  flow  of  urine 
from  the  ureters  embarrassed ;  these  latter  are 
also  distended  by  the  urine  standing  in  them, 
and  suffer  a  great  degree  of  lateral  pressure 
from  the  accumulated  urine.  Still  further,  the 
accumulation  of  a  large  quantity  of  urine  in 
the  bladder  and  ureters  acts  on  the  kidneys 
and  their  function  as  a  hindrance.  Since  the 
urine  cannot  flov/  freely  out  of  the  renal  tubules 
on  account  of  the  stagnation,  the  kidneys  must 
work  with  increased  secreting  power  and  pres- 
sure, in  order  to  overcome  the  back  pressure  of 
the  urine  accumulated  in  the  bladder  and  ure- 
ters. This  increased  secretory  pressure  finds 
its  confirmation  in  the  evidence  of  a  greater  or 
less  amount  of  albumen  in  the  still  spontane- 
ously passed  urine.  If  now  in  such  cases  the 
accumulated  urine,  which  perhaps  for  years  had 
exerted  a  strong  lateral  and  back  pressure  in 
the  urinary  tract,  be  all  at  once  evacuated  by 
catheterization,  then  there  immediately  ensues 
such  a  negative  fluctuation  in  the  pressure,  I 
might  say  such  a  hypersemia  ex  vacuo,  that  in- 


70     Neuroses  of  the  Crenito-Ur'uiarij  System 

flammatory  processes  must,  as  a  rule,  follow  as 
the  necessary  consequence  of  this  disturbance. 

In  the  more  favorable  cases  only  mucous  or 
purulent  catarrh  of  the  bladder,  of  the  pelvis  of 
the  kidney  and  ureters,  will  take  place  from  this 
hyperiemia  ex  vacuo ;  we  shall  then  have  only 
a  cystitis  or  cystopyelitis.  In  tlie  more  severe 
cases,  to  the  purulent  cystopyelitis  are  added 
parenchymatous  inflammations  of  the  prostate, 
of  the  bladder,  and  the  rest  of  the  urinary  appa- 
ratus, usually  with  abscess  formation.  In  other 
severe  cases  a  parencliymatous  haemorrhage  of 
the  whole  urinary  tract  is  added  to  the  already 
present  cystop3'elitis,  and  by  decomposition  of 
the  urine  suppuration  in  the  bladder  is  engend- 
ered. Finally,  in  severe  cases  the  kidnejs  also 
will  react,  presenting  usually  the  symptoms  of 
nephritis  sup23urativa. 

Since,  then,  these  unpleasant  symptoms  after 
catheterization  are  not  to  be  counted  as  of  rare 
occurrence,  it  is  enjoined  to  manage  such  cases 
with  the  greatest  precaution.  If  the  paresis  of 
the  bladder  be  somevi^hat  advanced,  it  is  impor- 
tant to  have  the  patient  go  immediately  to  bed. 
I  never  completely  empty  the  bladder  at  once, 
that  is,  at  the  first  examination  of  the  patient. 
If  the  bladder  contain  a  large  amount  of  urine, 
I  never  at  the  first  sitting  draw  more  tlian  400 
to  500  c.c.  I  send  the  patient  home,  have  him 
go  to  bed,  and  then  empty  the  bladder  gradually 


in  the  Male.  71 

but  completely.  If  the  bladder  contain  at  the 
first  catheterization  less  than  400  c.c.  of  urine, 
and  I  empty  it  completely  without  meaning  to, 
I  do  not  allow  the  patient  to  depart  with  an 
empty  bladder,  but  I  inject  into  his  bladder  100 
c.c.  of  a  1-2  per  cent,  solution  of  carbolic  acid 
and  have  him  immediately  go  to  bed.  Only 
when  the  patients  promise  to  keep  their  beds 
for  some  time  (2  or  3  weeks)  is  it  possible,  in 
advanced  paresis  of  the  bladder  with  relatively 
mild  reactive  inflammatory  processes  of  the 
urinary  organs,  to  gradually  restore  the  orig- 
inal relations  of  pressure  within  the  latter  by 
means  of  regular  catheterization ;  and  notwith- 
standing the  patient  is  in  bed,  still  sometimes 
very  violent  symptoms  on  the  part  of  the  urin- 
ary system  occur. 

After  the  patient  has  undressed  himself  and 
gone  to  bed  the  bladder  is  completely  emptied 
by  means  of  a  soft  catheter  and  washed  out 
with  a  1-2  per  cent,  solution  of  carbolic  acid ; 
about  100  c.c.  of  this  solution  are  then  left 
in  the  bladder.  The  carbolic  acid  solution  is 
left  in  the  bladder  after  each  catheterization  ; 
only  the  quantity  is  gradually  diminished  to  a 
few  cubic  centimetres,  corresponding  to  the  re- 
turning contractile  power  of  the  bladder.  The 
injection  of  the  carbolized  solution  into  the 
bladder  has  the  advantage  that  the  bladder  is 
not   left  completely  empty,  and  that  its  walls 


72     Neuroses  of  the  Genito-Urinary  S>jstem 

need  not  rub  against  each  other,  which  some- 
times causes  very  painful  sensations  to  the  pa- 
tient. The  carbolic  acid  also  has  the  advantage 
over  other  fluids  of  effectuall}'  checking  the 
growth  of  bacteria,  which,  with  the  prevailing 
negative  pressure  in  the  urinary  tract,  may  pene- 
trate unresisted  from  without  even  to  the  kid- 
neys. Pressure  on  the  bladder  with  the  palm 
of  the  hand  over  the  symphj'sis  I  consider  un- 
necessary, because,  with  the  soft  catheter,  the 
bladder  is  completely  emptied  by  siphon  action 
with  a  facility  corresponding  to  the  lowering  of 
the  outer  end  of  the  catheter.  In  the  case  of 
beginning  inflammatory  action  in  the  bladder, 
moreover,  this  pressure  with  the  hand  much 
oftener  promotes  the  occurrence  of  parenchym- 
atous processes. 

When  paresis  of  a  milder  form  is  present,  so 
that  the  patient  is  still  able  to  pass  his  urine 
spontaneously  after  catheterization,  a  complete 
emptying  and  washing  out  of  the  bladder  by 
]neans  of  the  catheter  once  a  day  is  sufficient. 
"When,  however,  the  patient  can  no  longer  urin- 
ate spontaneously  after  catheterization,  then  at 
least  three  times  dail}',  and  if  severe  vesical 
tenesmus  should  be  present,  still  oftener,  must 
the  bladder  be  emptied  and  washed  out  with  a 
solution  of  carbolic  acid. 

In  the  after-treatment  the  use  of  drugs  as  well 
as  galvanism  and  a  course  of  bathing  at  a  moder- 


in  the  Male.  73 

ate  degree  of  heat  may  be  employed  with  advan- 
tage, such  as  has  already  been  described. 

In  paresis  and  paralysis  of  the  sphincter,  where 
incontinence  of  urine  is  present  and  the  patient 
is  obliged  to  wear  a  urinal,  a  more  frequent  cath- 
eterization, every  1,  2,  or  3  hours,  in  connection 
with  galvanic  treatment  of  the  sphincter,  is  to  be 
recommended.  When  the  sphincter  is  gradually 
strengthened  by  the  electricity,  then  the  cathet- 
erization may  be  performed  at  gradually  length- 
ening intervals. 

Among  the  motor  neuroses  of  the  urinary  ap- 
paratus belongs,  finally,  enuresis.  This  neurosis 
is  essentially  a  phenomenon  of  childhood,  and 
usually  disappears  with  the  development  of 
puberty.  By  enuresis  is  understood  the  invol- 
untary evacuation  of  normal  urine  in  childhood, 
the  urinary  organs  being  otherwise  normal.  By 
this  definition  all  those  conditions  which  are 
associated  with  increased  desire  to  urinate  and 
with  affections  of  the  urinary  apparatus,  are 
excluded. 

In  the  earliest  childhood  urination  and  defeca- 
tion take  place  without  any  subjective  sensa- 
tions. The  slightest  contractions  of  the  bladder 
and  of  the  rectum  suffice  to  expel  the  urine  and 
faeces,  since  the  resistance  of  the  sphincters  is 
wanting.  After  the  first  year  of  life  children 
begin  to  voluntarily  hold  back  the  faeces,  while 
the  urine  still  flows  involuntarily,  often  against 

4    D 


74     Neuroses  of  the  G-enito-  Urinary  System 

the  will  of  the  little  one.  The  ability  to  hold 
the  urine  back  at  will  is  usually  established  at 
about  the  end  of  the  second  year,  that  is,  after 
the  first  dentition. 

Now,  children  who  after  this  period  are  not 
yet  able  to  hold  back  the  urine,  and  who  have 
neither  diseased  urinary  organs  nor  abnormal 
urine,  suffer  from  enuresis.  Yet  enuresis  may 
first  appear  suddenly  iu  later  years,  usually,  in- 
deed when  the  organism  is  weakened  by  disease 
and  the  child  appears  to  be  much  run  down. 

Enuresis  occurs  either  in  sleep  (at  night), 
which  is  usually  the  case,  and  is  then  called 
enuresis  nocturna,  or  bed-wetting;  or  it  occurs 
only  by  day  and  then  only  after  vigorous  bodily 
movement  and  muscular  action,  such  as  running 
up  stairs,  laughing,  gymnastics,  cougliing,  etc., 
and  is  called  enuresis  diurna.  In  still  other  cases 
involuntary  urination  takes  place  by  day  as  well 
as  by  night,  and  the  condition  is  then  called  enu- 
resis confinua.  With  regard  to  the  manner  of 
occurrence  the  enuresis  is  continual,  repeating 
itself  regularly  every  day ;  or  it  is  periodical, 
occurring  irregularly. 

Respecting  the  aetiology,  the  various  enfeebled 
conditions,  as  anaemia,  scrofula,  rachitis,  etc., 
were  formerly  considered  of  first  importance, 
yet  these  do  not  explain  all  cases.  Not  infre- 
quently very  well  developed,  sturdy,  and  rosy- 
cheeked    children    are  found    who    suffer  from 


in  the  Male.  75 

enuresis,  while  among  the  great  number  of 
rachitic  and  scrofulous  children  only  a  very 
small  proportion  are  affected  with  this  condi- 
tion. In  other  cases,  too  sound  sleep  is  sug- 
gested as  a  cause,  but  wrongly.  Most  healthy 
children  sleep  so  soundly  that  they  can  be  un- 
dressed and  moved  from  one  bed  to  another 
without  awaking,  yet  they  do  not  wet  the 
bed.  Parents  often  complain  to  the  physician 
that,  although  they  wake  the  child  two  or  three 
times  during  the  night  and  compel  it  to  urinate, 
still  the  bed  is  found  wet  through  in  spite  of 
all.  Indeed,  not  infrequently  is  the  bed  found 
wet  directly  after  going  to  sleep,  although  the 
child  had  passed  his  urine  immediately  before. 
Trousseau,  Bretonneau,  and  Desault  have  sought 
for  the  cause  of  bed-wetting,  not  in  general 
weakness,  but  rather  in  abnormal  relations  of 
the  bladder  and  the  neck  of  the  bladder. 

Desault  assumes  that  sudden  violent  contrac- 
tions of  the  detrusors  of  the  bladder,  which  do 
not  suffice  to  bring  sleeping  children  to  con- 
sciousness, are  the  cause  of  enuresis.  This  expla- 
nation might  account  most  satisfactorily  for  the 
bed-wetting  which  sometimes  occurs  as  a  sequel 
to  cystitis,  pyelitis,  and  lithiasis.  With  normal 
urine  and  a  normal  condition  of  the  urinary 
organs,  spasmodic  contraction  of  the  detrusors 
occurring  in  sleep  is,  to  say  the  least,  very  prob- 
lematical.    Trousseau  and  Bretonneau  consider 


76     JVeuroses  of  the  Genito-  Urinary  System 

enuresis  a  neurosis  of  the  neck  of  the  bladder. 
Inasmuch  as  they  regard  the  neck  of  the  bhad- 
der  as  identical  with  the  external  sphincter, 
■^heir  view  is  the  only  correct  one.  Guersant 
assumes  a  congenital  weakness  (imperfect  de- 
velopment) of  the  sphincter,  yet  this  opinion 
is,  at  most,  applicable  only  to  certain  cases.  Still 
other  authors  suppose  a  hyperresthesia  of  the 
fundus  of  the  bladder  or  of  the  vesical  mucous 
membrane  in  general.  They  would  say  that  the 
bladder  is,  after  all,  only  able  to  hold  a  small 
amount  of  urine,  and  that,  when  a  certain  quan- 
tity has  been  exceeded,  the  whole  mass  flows 
away.  Lebert  thinks  that  enuresis  nocturna  is 
brought  about  in  this  way:  that  during  sleep 
there  is  a  certain  degree  of  narcosis  of  the 
sphincter  in  such  children.  The  necessity  of 
passing  the  urine  is  not  felt  sufficiently  to 
arouse  consciousness,  and  is  satisfied  immediately 
and  without  heed,  so  that  the  bed  is  then  wet 
through.  My  idea  of  enuresis,  at  least  of  enu- 
resis nocturna,  coincides  with  that  of  Trousseau 
and  Bretonneau,  inasmuch  as  I  also  assume 
that  we  have  to  do  with  a  neurosis  in  this  form 
of  enuresis.  That  is  to  say,  I  believe  there  is  a 
disproportion  between  the  innervation  of  the 
detrusors  and  that  of  the  sphincter,  and  that  the 
sphincter  is  very  imperfectly  innervated.  Since 
this  condition  is  normal  from  the  expiration  of 
the  first  year  until  the  completion  of  dentition, 


in  the  Male.  77 

so  in  all  those  cases  in  which  the  bed-wetting 
does  not  cease  in  time,  enuresis  represents  the 
continuance  of  this  infantile  condition.  That 
enuresis  consists  only  in  an  imperfect  innervation 
of  the  sphincter  of  the  bladder,  is  shown  by  the 
results  which  are  attained  by  electrical  treatment. 
There  are  cases,  namely,  which  are  already  cured 
after  the  first  faradization  of  the  sphincter  and 
remain  so  henceforth.  Such  a  therapeutic  re- 
sult can  only  be  explained  by  imperfect  inner- 
vation, and  never  by  imperfect  development  of 
the  sphincter. 

Sex  exerts  no  influence  on  enuresis.  Some 
authors,  indeed,  assert  that  many  more  boys 
than  girls  are  affected  with  enuresis,  yet  this  is 
only  apparent.  With  girls  particularly,  when 
they  are  somewhat  advanced  in  years,  the  par- 
ents take  great  pains  to  conceal  this  condition, 
especially  as  they  know  that  the  enuresis  usually 
ceases  at  puberty. 

As  regards  age,  it  is  found  that  most  children 
are  affected  with  enuresis  between  the  third  and 
tenth  years,  yet  I  have  often  had  under  treat- 
ment girls  as  well  as  boys,  14,  15,  and  even  17 
years  old.  That  a  kind  of  bed-wetting,  espe- 
cially enuresis  continua,  may  often  be  brought 
about  by  lithiasis  (especially  phosphatic  stone), 
cystitis,  and  pyelitis,  and  further  by  inflamma- 
tory affections  of  the  vagina,  vestibule,  and  ure- 
thra in  girls,  such  as  are  sometimes  caused  by 


78     Neuroses  of  the  Genito-  Urinary  System 

masturbation,  has  been  already  mentioned.  It 
is  absolutely  necessary  that,  in  every  case,  the 
urine  as  well  as  the  genitals  of  a  child  affected 
with  enuresis  be  subjected  to  a  close  examina- 
tion. 

Having  satisfied  ourselves  as  to  the  condition 
of  the  urine,  we  proceed  to  the  inspection  and 
examination  of  the  hypogastric  region  and  the 
genitals.  The  bladder  is  carefully  examined 
by  palpation  in  order  to  ascertain  whether  it 
is  well  filled  or  not,  whether  there  is  retention 
of  urine,  etc.  Then  the  meatus  urinarius  is 
observed,  and,  in  girls,  especially  the  entrance 
to  the  vagina.  Sometimes  small  polypous  ex- 
crescences are  found  about  the  meatus  in  girls. 
If  these  are  cut  off  with  scissors  the  incontin- 
ence usually  ceases.  An  examination  with  the 
sound  is  not  always  necessary  if  the  urine  is 
found  to  be  normal. 

The  treatment  of  enuresis  may  be  general 
and  local.  For  feeble  children  quinine  and 
especially  preparations  of  iron  are  indicated, 
aromatic  baths  at  a  temperature  of  26°  Reau- 
mur [90°  Fahr.],  as  well  as  cold  sitz  baths  or  a 
mild  cold  water  cure  in  general.  A  visit  to 
the  country  and  mountains,  river  and  sea  bath- 
ing, sometimes  have  an  excellent  effect.  Bella- 
donna and  atropia  are  highly  recommended  by 
Trousseau  and  Bretonneau.  In  the  evening 
before  going  to  bed  0.01  extract  of  belladonna 


in  the  Male.  79 

or  0.0005  (1-120  gr.)  atropia  is  given.  With 
smaller  and  weaker  cliildren  these  preparations 
demand  great  precaution  ;  with  larger  and  stur- 
dier children  the  daily  dose  may  be  gradually 
increased  until  some  enlargement  of  the  pupils 
is  apparent.  At  any  rate,  treatment  with  these 
preparations  must  be  continued  for  months. 
Ergot,  as  well  as  tincture  of  nux  vomica,  have 
sometimes  given  good  results. 

The  best  method  of  treatment  in  these  cases, 
however,  is  the  local.  If  the  cause  of  the 
incontinence  is  found  in  a  weakness  of  the 
sphincter,  it  seems  logical  that  an  attempt  must 
be  made  to  strengthen  the  weakened  muscle. 
This  is  best  accomplished  by  electricity.  The 
earlier  cutaneous  metliod  gave  no  marked  re- 
sults. Also  the  method  with  the  catheter- 
formed  electrode,  as  used  in  the  incontinence 
of  adults,  is  not  practicable  with  children. 
Children  are  too  restless,  and  the  introduction 
of  the  urethral  electrode,  especially  in  boys, 
can  scarcely  be  performed  without  injury.  The 
application  of  this  electrode  also  not  infre- 
quently sets  up  urethritis  and  cystitis,  condi- 
tions which,  in  enuresis,  can  only  have  a  very 
harmful  influence.  Since,  then,  direct  treat- 
ment with  the  urethral  electrode  is  impracti- 
cable with  children,  I  have  brought  into  use, 
relying  on  surgical  experience,  the  indirect 
stimulation  of  the  sphincter  vesicae  through 
the  rectum. 


80     Neuroses  of  the  Genito-Urinaru  System 

It  is  a  well-known  fact  that  operations  per- 
formed in  the  lower  part  of  the  rectum  are  not 
infrequently  followed  by  complete  retention  of 
urine.  Cases  of  difficult  micturition  are  also 
met  with  in  which  the  urine  can  only  be  voided 
during  defecation.  This  simultaneous  action 
of  the  sphincter  ani  and  the  sphincter  vesicae 
externus  on  the  application  of  various  stimuli 
in  the  rectum  is  the  point  of  departure  of  this 
method  of  treatment,  which  also  finds  its  ex- 
planation in  the  anatomical  relations  of  this 
region. 

The  heemorrhoidal  nerves,  median  and  in- 
ferior, both  arising  from  the  pudic  branch  of 
the  sacro-coccygeal  plexus,  supply  together  the 
lower  part  of  the  bladder  with  the  sphincter 
vesicae,  also  the  sphincter  ani  externus  and 
internus,  and  finally,  in  women,  the  vagina.  It 
is  therefore  clear  that  an  electrical  stimulus 
applied  in  the  rectum,  is  transmitted  to  the 
neck  of  the  bladder,  sets  up  contractions,  and 
thereby  strengthens  the  sphincter  vesicae. 

I  use  for  this  purpose  an  ordinary  sledge- 
battery  [Schlitten-Apparat]  of  Dubois-Rey- 
mond,  which  is  armed  with  one  element.  One 
pole  of  the  induced  current  is  a  metallic  pin  as 
large  as  a  lead  pencil  and  7  cm.  long,  with  a 
wooden  handle  (Fig.  5),  which  is  well  oiled 
and  passed  into  the  rectum.  The  other  pole  is 
an    ordinary    sponge-holder,    and    in    boys    is 


in  the  Male.  81 

placed  on  the  raphe  of  the  perinseum ;  in  girls, 
however,  in  the  crease  of  the  buttock.  The 
current  must  at  first,  especially  in  small  chil- 
dren, be  very  weak  and  scarcely  per- 
ceptible, because  otherwise  the  children 
are  very  easily  frightened  and  cannot  be 
induced  to  allow  the  treatment  to  be 
continued.  Gradually  the  strength  of 
the  current  is  increased  to  the  limit 
of  endurance.  The  sittings  are  held 
daily,  or  at  least  every  other  day,  and 
usually  last  from  5  to  10  minutes.  The 
patient  lies  stretched  on  a  sofa.  The 
treatment  lasts  on  the  average  4  to  5 
weeks,  although,  when  relapses  occur,  it 
must  be  continued  still  longer. 

(5)  The  motor  neuroses  which  mani- 
fest themselves  in  the  sexual  system  are 
pollutions  and  spermatorrhoea. 

By  pollution  is  usually  understood  a 
copious  evacuation  of  semen  which  takes  t 
place  during  sleep,  generally  at  night,  I 
with  voluptuous  sensations  and  erect 
penis.  The  semen  is  ejaculated  spas- 
modically by  contractions  of  the  mus- 
cular tissue  of  the  seminal  vesicles  and 
urethra  (musculus  bulbo-cavernosus).        ^^^  ^ 

By   spermatorrhoea    is    understood    a    Rectal 
slight,  dribbling,  sometimes    continual,  ^^ectrocie. 
flow  of  semen,  without    erection    of  the   penis 

4* 


82     Neuroses  of  the  Q-enito-JJrinary  System 

and  without  especially  pleasurable  sensation. 
This  evacuation  of  semen  occurs  more  copiously 
after  defecation  or  at  the  end  of  micturition. 

Pollution  might  be  described  as  a  motor 
neurosis  of  the  sexual  apparatus  with  spasm  of 
the  muscular  coat  of  the  seminal  vesicle,  and 
spermatorrhoea  as  a  similar  neurosis  with  paresis 
of  the  ejaculatory  ducts. 

The  ideas  of  pollution  and  spermatorrhoea 
are  commonly  confused,  especially  as  there  are 
mixed  forms,  i.e.^  eases  of  spermatorrhoea  which 
sometimes  have  pollutions  also.  There  are  also, 
however,  perfectly  pure  forms,  and  therefore 
the  division  into  pollutions  and  spermatorrhoea 
must  be  retained.  There  are,  namely,  cases  of 
pollution  which  never  lose  semen  by  day,  after 
urination  or  defecation ;  likewise  there  are  pure 
cases  of  spermatorrhoea  which  never  have  pollu- 
tions, but  instead  of  them  daily  lose  semen  in 
small  quantities  and  often  continuousl3^ 

Other  authors  describe  nocturnal  and  diur- 
nal 23ollutions,  and  designate  as  spermatorrhoea 
every  discharge  which  is  not  chronic  gonor- 
rhoea, and  which  looks  viscid  and  whitish  or 
colorless.  This  classification  is  inappropriate, 
for,  where  so-called  poUutiones  diurnse  are  pres- 
ent, a  discharge  of  semen  is  also  usually  found 
after  defecation  and  urination ;  on  the  other 
hand,  in  the  case  of  a  viscid  and  turbid  dis- 
charge from  the  urethra,  the  diagnosis  of  sper- 


in  the  Male.  83 

matorrhoea  cannot  be  made  without  a  micro- 
scopical examination.  That  is  to  say,  there  is 
a  secretory  neurosis  of  the  prostate,  prostator- 
rhoea,  which  also  furnishes  a  viscid,  turbid  fluid, 
which  has,  however,  nothing  in  common  with 
semen,  as  will  be  more  fully  discussed  later  on. 
Curschmann  admits  nocturnal  and  diurnal  pol- 
lutions and  spermatorrhcEa,  and  at  the  same 
time  considers  spermatorrhoea  the  superlative 
degree  of  pollution. 

When  pollutions  occur  once  in  10  to  14  days, 
they  may  be  looked  upon  as  physiological;  if 
they  occur  much  oftener  they  are  pathological. 
Curschmann  will  not  allow  a  division  based  on 
the  frequency  of  the  pollutions,  but  holds  that 
pollutions,  even  when  they  occur  frequently, 
may  still  be  regarded  as  a  physiological  dis- 
charge of  semen  if  the  individual  affected  feels 
on  the  following  day  well  and  strong,  or  has  a 
sense  of  relief.  He  considers  pathological  on. 
the  other  hand,  all  those  pollutions,  even  when 
rarely  occurring,  after  which  the  patients  feel 
exhausted  and  languid,  and  suffer  from  head- 
ache and  impairment  of  mental  vigor. 

Since  the  semen  in  these  affections  plays  an 
important  r81e,  its  anomalies  should  here  be 
briefly  spoken  of. 

Normal  semen,  as  is  well  known,  is  a  mixture 
which  consists  of  the  secretions  of  the  testicles, 
of  the   seminal   vesicles,  of  the   prostate,  and 


84     Neuroses  of  the  Crenito-  Urinary  System 

other  accessory  glands  of  the  urinary  system. 
The  amount  discharged  at  one  time  is  some- 
times greater,  sometimes  smaller,  according  to 
the  continence  of  the  producer ;  ordinarily  it  is 
between  10  and  15  grammes. 

Normal  semen  has  a  whitish  color,  resembling 
boiled  starch  paste,  a  peculiar,  characteristic, 
heavy  odor,  and  an  alkaline  reaction.  Its  con- 
sistence immediately  after  ejaculation  is  hone}''- 
like  and  ropy ;  it  soon,  however,  stiffens  like 
gelatine,  to  become  again  yet  more  fluid  in  the 
course  of  5  or  10  minutes. 

The  semen,  having  been  poured  into  a  test- 
tube  and  allowed  to  settle,  is  found,  after  some 
hours,  to  have  separated  into  two  layers.  In 
normal  semen  the  two  layers  are  of  equal  bulk. 
The  lower  layer  is  white,  opaque,  and  consists 
of  the  cellular  constituents  of  the  semen,  in 
normal  semen  of  spermatozoa.  The  upper  layer 
is  turbid  and  translucent,  the  microscope  show- 
ing only  a  few  cells  and  some  detritus.  From 
the  thickness  of  the  layer  containing  sperma- 
tozoa it  is  sometimes  possible  to  arrive  at  a 
conclusion  as  to  the  generative  power  of  the 
semen  in  question. 

If  a  drop  of  fresh  semen  is  examined  under 
the  microscope,  a  picture  full  of  move:nent  will 
be  seen.     As  if  an  ant-hill  had  been  stirred  up^ 
with  a  stick,  so  the  spermatozoa  in  lively  motion 
confusedly  squirm  about.     Besides  these  are  to 


in  the  Male. 


85 


be   seen  only  some   epithelial   cells,   spermatic 
cells,  and  a  little  fine  granular  matter. 

The  spermatozoa  of  normal  semen  consist  of 
an  oval  or  flattened,  pear-shaped,  shovel-like 
head  and  a  long  thread-like  end  which  is 
divided  into  a  middle  piece  and  a  tail.  The 
middle  piece  and  tail  should  be  at  least  ten 
times  the  length  of  the  head.     The  spermatozoa 


Fig.  6.  —  Spermatic  Crystals.    300  diameters. 

should  be  present  in  large  numbers,  and  still 
show  movement  at  least  12  hours  after  evacua- 
tion. 

When  a  normal  semen  has  been  allowed  to 
stand  a  considerable  time,  on  the  second  or 
third  day  are  found,  at  first  only  single,  later  in 
greater  numbers,  colorless  transparent,  rhom- 
bcidal  crystals   (Fig.  6).     When  incompletely 


86     Neuroses  of  the  Grenito-  Urinary  St/stem 

crystallized,  these  crystals  appear  tapering  and 
rounded  at  tlie  ends.  A.  Bottcher  considers 
them  albuminoid  bodies,  other  authors  ammo- 
nio-magnesic  phosphate.  I  have  also  examined 
these  crystals,  and  found  that  they  consist  of 
phosphoric  acid  and  magnesia  ;  ammonia  I  could 
not  find. 

As  regards  the  amount  of  semen  discharged 
at  one  time,  it  is,  as  has  before  been  remarked, 
very  variable.  The  more  frequently  coitus  is 
repeated  the  smaller  will  each  time  the  amount 
become,  until  finally  only  a  few  drops  will  be 
painfully  produced.  The  more  continently  a 
man  lives,  on  the  other  hand,  the  greater  are 
the  amounts  of  semen  discharged  at  coitus. 
Nevertheless  there  are  two  extreme  conditions 
which  are  easily  distinguishable,  namely,  poli/- 
spermia  and  aspermia. 

Polt/spermia,  the  ejaculation  of  a  large  amount 
of  semen  at  one  coitus,  is  relatively  seldom 
observed.  I  have  only  once  examined  such  a 
case.  A  man  about  40  years  old,  robust,  yet 
very  nervous,  who  suffered  with  polyuria,  cys- 
tospasraus,  and  various  neuralgic  pains,  com- 
plained to  me  that  with  nocturnal  pollutions 
he  lost  such  a  large  amount  of  semen  that  his 
drawers  and  the  bed  were  each  time  thoroughly 
wet  through ;  and  that  after  coitus  the  women 
declared  that  he  must  have  urinated,  for  they 
felt  themselves  so  wet.     I  had  the  patient  col- 


in  the  Male.  87 

lect  the  semen  discharged  at  one  coi'cus,  and 
found,  indeed,  an  extraordinary  amount,  about 
35  grammes.  Yet  the  patient  told  me  that  he 
had  not  been  able  to  collect  the  whole  of  the 
semen.  The  semen  showed  normal  and  living 
spermatozoa.  After  settling,  it  showed  that  the 
fluid  constituents  of  the  semen,  in  comparison 
with  the  white  lower  layer  comprising  the  cel- 
lular elements,  were  increased. 

Somewhat  more  frequent  is  aspermia  or 
aspermatismus,  the  absence  of  semen.  It  is 
either  a  permanent  or  a  temporary  condition. 
Its  cause  is  to  be  sought  either  in  a  mechanical 
obstacle  to  the  discharge  of  the  semen  (obliter- 
ation of  the  ejaculatory  ducts),  or  in  the  fact 
that  no  semen  is  produced,  or,  if  semen  is  pro- 
duced, that  it  cannot  be  brought  to  light  by 
sexual  stimulus. 

In  one  case  I  have  seen  aspermia  occur  in  a 
married  man  after  prostatitis  suppurativa,  he 
not  being  able  to  produce  semen  during  coitus, 
although  this  had  been  perfectly  possible  before 
the  -prostatitis.  In  another  case  I  have  observed 
aspermia  in  a  robust  man,  24  years  old,  which 
must  be  a  very  rare  occurrence.  This  man  con- 
sulted me  as  to  whether  he  might  contract  a 
marriage,  since  he  was  perfectly  able  to  perform 
the  act  of  sexual  intercourse,  yet  he  had  never 
in  coitus  nor  as  pollution  produced  a  discharge 
of  semen.  I  was  at  first  distrustful  of  the  patient's 


88     Neuroses  of  the  Crenito-  Urinary  System 

story,  but  was  able,  after  long  observation,  to 
convince  myself  of  the  correctness  of  his  asser- 
tions. The  young  man  had  never  had  any  sex- 
ual disease.  His  genital  organs  were  normally 
formed  ;  examination  with  the  sound  met  with 
no  obstruction  in  the  prostatic  urethra.  I  tried 
faradization  of  both  testicles,  in  order  to  excite 
the  formation  of  semen,  but  without  result.  In 
spite  of  many  times  re})eated  coitus  and  other 
sexual  excitement,  the  patient  was  unable  to 
produce  semen.  Several  months  later  I  received 
from  him  a  letter,  in  which  he  informed  me  that 
he  still  had  no  semen  ;  and  he  recently  again 
sought  my  professional  advice.  Since  the  geni- 
tal apparatus  of  this  patient  was  entirely  nor- 
mal, and  the  man  had  never  had  a  pollution  up 
to  his  24th  year,  nor  had  been  able,  in  spite 
of  oft-repeated  sexual  excitement,  to  ejaculate 
semen,  I  believe  that,  in  this  case,  we  have  to 
do  with  an  absolute,  permanent  aspermatismus. 
Whether  in  such  cases  the  non-excitability  of 
the  reflex  centre  of  ejaculation  is,  according  to 
Schulz,  to  be  considered,  I  do  not  venture  to 
express  an  opinion. 

Cases  of  temporary  aspermatismus,  on  the 
other  hand,  frequently  occur.  Usually,  in  such 
patients,  gonorrhoea  with  prostatitis  has  gone 
before.  These  persons  also  generally  suffer  at 
the  same  time  with  several,  and  often  very  dif- 
ferent, neuroses,  now  of  the  urinary  and  now  of 


in  the  3Iale.  89 

the  sexual  system.  The  patients  have  erection 
of  the  penis  and  perform  the  act  of  coition,  yet, 
in  spite  of  every  effort,  they  are  not  able  to 
ejaculate  semen. 

As  for  the  color  of  semen,  it  may  be 
bloody,  ^.e.,  reddish  brown,  or  yellow,  contain- 
ing pus.  Both  the  appearances  occur  in  prosta- 
titis and  inflammation  of  the  seminal  vesicles. 
These  shades  of  color  are  best  seen  when  the 
semen  has  dried  on  white  cloth.  In  the  dry 
condition  the  stain  is  sometimes  observed  to  be 
bordered  with  blue  or  violet ;  this  indicates  a 
large  amount  of  indigo  in  the  semen.  If  pus 
and  indigo  are  present  at  the  same  time,  beauti- 
ful bluish  green  spots  of  semen  may  be  seen. 

The  spermatozoa  likewise  appear  under  varied 
conditions.  Sometimes  they  are  fresh  and  lively ; 
sometimes,  however,  semen  is  discharged  which 
contains  entirely  motionless  spermatozoa.  I 
have  seen  cases  of  an  a,dvanced  stage  of  sper- 
matorrhoea, in  which,  after  passing  urine,  a 
large  quantity  of  semen  was  discharged  which 
looked  normal,  but  which  contained  sperma- 
tozoa wholly  motionless.  The  number  also  of 
the  spermatozoa  may  be  greatly  diminished,  as 
may  sometimes  be  observed  in  old  age,  or  after 
oft-repeated  sexual  excesses.  Again,  the  form 
of  the  spermatozoa  sometimes  suffers  changes. 
Thus,  not  infrequently,  in  inflammation  of  the 
seminal  vesicles,  with  or  without  inflammation 


90      Neuroses  of  the  Genito- Urinary  System 

of  the  testicles,  are  seen,  in  the  semen  contain- 
ing blood  and  pus,  motionless  spermatozoa  with 
shortened  or  spirally  twisted  tails,  or  even  the 
shovel-shaped  heads  alone. 

Indigo  not  infrequently  appears,  on  micro- 
scopic examination,  among  the  spermatozoa.,  in 
the  form  of  beautiful  flakes  of  a  cornflower 
blue,  or  as  bluish-black  scales. 

When  spermatozoa  ai'e  entirely  absent  in 
the  semen,  the  condition  is  called  azoospermia. 
Since  in  this  semen  the  fructifying  element  is 
wanting,  there  is  impotentia  generandi.  It  is 
well  to  distinguish  this  condition  from  impo- 
tentia coeundi,  for  patients  affected  with  azoo- 
spermia are  able  to  perform  the  act  of  coitus 
often  and  vigorously,  and  usually  have  no  idea 
that  their  semen  is  abnormal. 

Azoospermia  usually  occurs  after  epididj'^mitis 
gonorrhoica,  especially  Avhen  the  latter  was  bila- 
teral. Yet  this  is  not  absolutely  necessary,  since 
an  inflammation  of  the  spermatic  cords  alone 
may  bring  about  this  condition.  Azoospermia 
takes  place  by  obliteration  of  the  vasa  defer- 
entia ;  the  passage  of  the  secretion  from  the 
testicles  to  the  vesiculte  seminales  is  thereby 
stopped,  and  the  spermatozoa  can  no  longer  ap- 
pear in  the  ejaculated  semen.  The  semen  repre- 
sents only  the  secretion  of  the  vesiculse  semi- 
nales, mixed  with  that  of  the  urethral  glands. 

If  semen  of  this  kind  be  examined  in  a  fresh 


in  the  Male.  91 

state,  it  will  be  noticed  that  it  has  been  dis- 
charged in  normal  amount.  It  will  also  be 
noticed  that  it  coagulates  like  normal  semen  ; 
only  in  the  color  will  a  slight  difference  be  ob- 
served. The  semen  is  much  more  transparent 
and  watery.  If  it  be  examined  microscopically, 
sometimes  lymph  corpuscles  will  be  seen,  some- 
times colloid  degenerated  epithelium,  and  again, 
molecular  fat.  If  allowed  to  settle  some  hours, 
there  are  seen  in  great  numbers  and  well  formed 
those  large,  transparent  crystals  of  phosphoric 
acid  and  magnesia  —  the  spermatic  crystals. 
From  this  account  of  azoospermia  after  oblit- 
eration of  the  vasa  deferentia,  it  appears  clear 
that  the  ejaculated  semen  consists  of  the  secre- 
tion of  the  seminal  vesicles,  and  that  the  testi- 
cles furnish  only  the  fructifying  constituent,  the 
spermatozoa.  Since  the  spermatic  crystals  also 
occur  in  azoospermia,  it  can  be  affirmed  with 
certainty  that  they  are  peculiar  to  the  secretion 
of  the  seminal  vesicles. 

The  quick  or  tardy  appearance  of  these  crys- 
tals affords  an  inference  as  to  the  fructifying 
power  of  the  semen.  That  is  to  say,  if  a  semen 
contain  many  and  living  spermatozoa,  the  crys- 
tals appear  very  late,  sometimes  not  until  the 
third  day,  because  crystallization  is  impossible 
in  a  fluid  full  of  movement,  such  as  a  normal 
semen  containing  many  living  spermatozoa.  If, 
however,  the  semen  contain  motionless  sperma- 


92     Neuroses  of  the  Genito-Urinary  System 

tozoa  or  none  at  all,  then  the  spermatic  crystals 
appear  in  the  course  of  half  an  hour.  The  ear- 
lier, therefore,  and  the  more  perfectly  formed  do 
these  crystals  appear,  and  the  greater  is  their 
number,  just  so  much  the  worse  is  the  semen 
containing  them. 

The    commonest    causes    of    pollutions    and 
sperm atorrhcea  are  sexual  excesses,  and  espe- 
cially    masturbation.      Sexual    excesses    imply 
protracted  erections,  and  each  erection  is  asso- 
ciated with  swelling  of  the  caput  gallinaginis. 
Through  this  too  frequent  and  long-continued 
swelling   in    the    prostatic  urethra,  a  catarrhal 
condition  becomes  localized  in  the  caput  gallin- 
aginis, and  a  marked  h3^perfemia  and  hypera^s- 
thesia   in    the    whole   pars   prostatica    urethras, 
whence,  originating   reilexly,   come   sometimes 
pollutions  and  sometimes  spermatorrhoea.     That 
a  catarrhal  process  in  the  caput  gallinaginis  is  at 
times  involved,  we  see  from  tlie  fact  that,  in  the 
urine  of  patients  affected  with  pollutions,  there 
are  sometimes  shreds  floating  which  consist  of 
pus  coipuscles,  epithelium,  and  spermatozoa.     If 
such  patients  be  examined  with  the  sound,  the 
prostatic  urethra  is  found  so  sensitive  that  the 
patients  utter  loud  cries  of  pain.     If  the  muc- 
ous membrane  of  this  region  be  examined  with 
the  endoscope,  it  is  found  to  be  of  a  dark,  cherry- 
red  color,  swollen,  partly  denuded  of  epithelium, 
and  bleeding  easily. 


in  the  3fale.  93 

Inflammations  of  the  prostate  also  have  some- 
times pollutions  and  sometimes  spermatorrhoea 
as  a  consequence.  Especially  in  chronic  gonor- 
rhoea, after  inflammation  of  the  seminal  ves- 
icles, pollutions  make  their  appearance  as  never 
before.  In  chronic  prostatitis  and  hypertrophy 
of  the  prostate,  on  the  contrary,  spermatozoa 
can  almost  constantly  be  seen  in  the  urinary 
sediment,  as  a  proof  that,  through  inflammatory 
processes  or  gland  enlargement,  the  sphincters 
of  the  ejaculatory  ducts  have  been  rendered 
insufficient. 

In  affections  of  the  central  nervous  system, 
sometimes  pollutions  and  sometimes  spermator- 
rhcea  are  known  to  occur.  A  too  tight  prepuce, 
phimosis,  is  also  not  infrequently  the  cause  of 
pollutions.  I  have  repeatedly,  in  cases  of  phim- 
osis, by  its  removal,  cured  pollutions  as  well  as 
impotence.  Nervousness  alone  would  hardly 
produce  discharges  of  semen,  yet  they  are  parti- 
cularly obstinate  and  severe  in  nervous  persons 
who  have  at  the  same  time  committed  sexual 
excesses  or  masturbation. 

The  diagnosis  of  seminal  discharge  must 
always  be  confirmed  microscopically.  Of  course 
the  presence  of  spermatozoa  plays  here  the  most 
important  r81e,  yet  only  when  the  semen  of  the 
individual  in  question  actually  contains  sperma- 
tozoa. In  azoospermia,  which  may  be  asso- 
ciated with  pollutions  or  with  spermatorrhoea, 


9-4     Neuroses  of  the  Crenito-  Urinary  System 

the  absence  of  spermatozoa  is,  of  course,  insuf- 
ficient evidence.  In  such  cases  a  drop  of  the 
fluid,  on  a  slide,  must  be  covered  over,  and  after 
some  hours  examined  for  tlie  characteristic  sper- 
matic crystals. 

If  spermatozoa  be  found  constantly  or  very 
frequently  in  the  urinary  sediment;  if  the  patient 
discharge  after  urination  or  after  defecation  a 
large  amount  of  semen  ;  or,  finally,  if  it  be  often 
possible  to  squeeze  out  of  the  penis  a  whitish 
drop  containing  spermatozoa,  then  the  patient 
suffers  with  spermatorrhoea.  If,  however,  the 
result  of  this  examination  be  negative,  and  only 
a  copious  discharge  of  semen  take  place  at 
night,  then  the  patient  suffers  with  pollutions. 
Mixed  forms  are,  indeed,  not  rare,  yet  either 
the  symptoms  of  pollution  or  those  of  sperma- 
torrhoea preponderate,  so  that  this  distinction 
may  almost  always  be  easily  made. 

If  pollutions  occur  very  often,  the  most  varied 
general  symptoms  are  associated  with  them, 
especially  symptoms  of  irritation  of  the  general 
nervous  system,  while,  in  the  true  form  of  sper- 
matorrhoea, symptoms  of  depression,  impotence, 
and  melancholy  are  most  prominent.  Patients 
with  frequent  pollutions  usually  suffer  from 
faintness  and  dizziness  in  the  head,  which  symp- 
toms appear  on  the  morning  after  the  pollution, 
and  render  the  patient  incapable  of  every  men- 
tal exertion.      Sometimes   there  is  a  dragging 


in  the  Male.  95 

pain  in  the  occipital  region.  The  patients  exhi- 
bit a  reflex  irritability,  so  greatly  exaggerated 
that  they  start  at  every  unexpected  noise,  at 
every  moment  the  face  changes  color,  the  eye- 
balls roll  unsteadily,  and  a  disturbance  of  speech, 
in  the  highest  degree  of  excitement,  is  so  far 
noticeable  that  the  voice  fails  at  certain  words. 
Very  often  difficulty  in  breathing  and  nervous 
palpitation  of  the  heart  occur.  If  the  patients 
are  made  to  strip,  on  observing  carefully  the 
bare  body  a  continual,  slight,  subsultus  ten- 
dinum  will  be  noticed. 

In  spermatorrhoea  it  is  not  infrequently  found 
that  the  testicles  and  the  skin  of  the  external 
genitals  are  less  sensitive  to  electrical  stimula- 
tion ;  while  the  urethra  is  hypersesthetic. 

The  treatment  of  seminal  discharges  is  both 
general  and  local.  At  the  same  time  a  strictly 
regulated  habit  of  life  must  be  prescribed  for 
these  patients.  It  is  clear  that,  before  all, 
sexual  excitement  and  masturbation  must  be 
avoided;  likewise  is  it  necessary  for  the  pa- 
tients, at  least  temporarily,  to  avoid  severe  phy- 
sical or  mental  labor.  An  invigorating  trip  to 
the  country  or  mountains,  in  connection  with  a 
milk  or  cold  water  cure,  as  well  as  river  or 
sea  bathing,  are  especially  indicated.  The  diet 
should  consist  of  easily  digestible  dishes,  and 
should  be  entirely  non-stimulating.  Spices, 
spirituous  liquors,  strong  coffee  and  tea  should 


96      Neuroses  of  the  Crenito-  Urinary  System 

be  avoided.  It  is  also  better  to  eat  often  during 
the  day,  and  not  too  much  at  a  time.  Espe- 
cially in  the  evening,  before  going  to  bed,  only 
an  extremely  frugal  meal,  with  little  drink, 
should  be  partaken  of,  in  order  that  neither  the 
stomach  and  intestines  nor  the  bladder  may  be 
overloaded. 

The  sleep  should  not  last  too  long,  and  early 
rising  is  particularly  to  be  recommended.  The 
bed  should  have  a  rather  hard,  well-filled  mat- 
tress. The  pillow  should  be  filled  with  horse- 
hair, and,  for  covering  the  body,  thick,  heavy, 
and  heating  coverlets  should  never  be  used. 
The  patients  should  never  lie  on  the  back ;  and 
when  they  awake  in  the  morning  they  should 
immediately  empty  the  bladder,  for,  in  the  dor- 
sal position,  the  distended  viscera  press  on  the 
return  blood-vessels,  and  thereby  increase  the 
hyperemia  of  the  prostatic  urethra.  The  in- 
creased hypersemia  intensifies  also  the  hyper- 
sesthesia  of  this  part,  and  it  requires  then  rela- 
tively very  slight  irritation  (for  instance,  a 
heavy  coverlet,  a  touch  of  the  hand,  etc.),  to 
set  up  reflex  contractions  of  the  seminal  ves- 
icles, that  is  to  say,  pollutions. 

Quinine  and  iron  as  tonics  are  indicated  when 
weakness  and  anaemia  predominate.  From  cam- 
phor and  from  lupulin  I  have  seen  no  great 
results,  and  just  as  little  from  belladonna  and 
valerian.     On  the  other  hand,  bromide  of  potas- 


in  the  Male.  97 

sium  works  excellently,  but  large  doses  must  be 
given.  I  usually  give  from  3  to  4  grammes  a 
da}^,  dissolved  in  a  large  quantity  of  milk  or 
sugar  water.  Sometimes,  especially  in  sperma- 
torrhcea,  ergot  works  very  well,  of  which  at 
least  half  a  gramme  daily  must  be  taken. 

The  electrical  treatment  is  carried  out,  accord- 
ing to  Benedikt  and  Schulz,  with  the  constant 
current,  and  lasts  from  6  to  10  weeks,  with 
sittings  of  2  to  3  minutes  4  to  6  times  a  week. 
The  current  should  be  so  weak  as  to  be  just 
felt.  The  copper  pole  is  placed  over  the  lum- 
bar vertebrae,  and  with  the  zinc  pole  are  suc- 
cessively and  repeatedly  stroked  the  spermatic 
cords,  the  penis,  and  the  perinaeum.  By  this 
procedure  the  abnormal  reflex  excitability  of 
the  spinal  cord  should  be  reduced. 

The  best  method  of  managing  the  seminal 
emissions,  however,  is  the  local.  Keeping  in 
mind  that,  by  sexual  excesses  or  masturbation, 
changes  in  the  prostatic  urethra  have  been 
brought  about,  from  which  arise,  reflexly,  pol- 
lutions and  spermatorrhoea,  the  advantage  of 
local  treatment  will  be  obvious. 

In  many  cases  the  treatment  with  large  and 
heavy  metallic  sounds  alone  has  proved  benefi- 
cial. Once  a  day,  or  at  least  every  other  day, 
the  sounds  are  passed  into  the  bladder,  the  pa- 
tient lying  on  his  back,  and  left  in  for  a  period 
gradually  increasing  from  5  to  30  minutes.     As 

5    E 


98     Neuroses  of  the  Genito-Urinary  System 


large  a  sound  should  always  be  chosen  as  can 
be  made  to  pass  the  orificium  urethrfe ;  usually 
Nos.  20  to  26  of  the  Charriere  scale  are  em- 
ployed. These  sounds  act 
through  pressure  on  the  pars 
prostatica  as  well  as  by  their 
weight.  If  there  is  at  the  same 
time  marked  hyperaisthesia  of 
the  urethra,  we  may  begin  with 
passing  bougies,  and  for  this 
purpose  Pitha  gives  preference 
to  the  wax  bougie  over  all 
others. 

In  very  much  the  same  way, 
and  sometimes  much  better, 
works  the  cold  sound  (called 
psychrophor  by  Winternitz) 
(Fig.  7).  This  is  a  metallic, 
closed,  double  catheter,  to  the 
inflow  and  outflow  of  which 
lono'  rubber  tubes  are  attached. 
The  end  of  the  tube  from  the 
inflow  is  placed  in  an  elevated 
vessel  filled  with  cold  water ; 
the  outflow  leads  to  an  empty 
/,'  yJ  vessel  on  the  floor.  By  suction 
on  the  outflow  tube  the  current 
of  cold  water  is  started,  and 
flows  through  the  double  sound 
into    the  lower  vessel    and    keeps    the    sound 


Fig.  T. 
The  Cold  Sonne! 
(Psychrophor). 


in  the  Male.  99 

uniformly  cold.  Here  the  metallic  pressure 
acts  in  connection  with  the  cold  on  the  pros- 
tatic urethra.  The  temperature  of  the  water 
varies.  It  is  usual  to  begin  with  water  that  has 
stood  in  the  air  (16°  to  18°  Rdaumur  [68°  to 
72°  Fahr.]),  and  gradually  pass  to  fresh  spring 
water.  I  have  often  observed  that  very  cold 
water  is  not  well  borne,  while  water  at  the 
ordinary  temperature  works  very  well.  A 
sitting  lasts,  at  first,  5  minutes,  increasing  to 
30  minutes.  Should  symptoms  of  catarrh  of  the 
bladder  arise,  the  treatment  must  be  suspended 
for  a  few  days. 

Astringents  also  work  very  beneficially,  in  a 
liquid  form  as  well  as  in  the  form  of  small  ureth- 
ral suppositories,  of  the  size  of  a  barleycorn,  in- 
troduced into  the  pars  prostatica  by  means  of 
Dittel's  porte-remede.  For  using  astringents  in 
the  liquid  form,  my  short  catheter-syringe  may 
be  employed  to  advantage,  in  the  same  manner 
as  described  on  page  28.  If  a  more  powerful  and 
lasting  effect  is  to  be  produced  on  the  mucous 
membrane,  urethral  suppositories  and  Dittel's 
porte-remede  are  used  (Fig.  8). 

In  the  figure,  A  represents  a  catheter,  with 
open  end  and  a  short  curve,  made  of  silver.  This 
is  closed  by  an  obturator  B,  also  made  of  silver. 
The  obturator  ends  in  an  olive-shaped  bulb, 
which  just  fits  in  the  opening  of  the  catheter 
C,  and  rounds  off  the  end.     At  the  distal  end  is 


100  Keuroses  qtiite  Genito- Urinary  Si/stem 

a  knolBv^lii^ by  means  of  a  bayonet-lock  may 

be  fix^  i^niovabl}^  in  the  catheter. 

•^  U9^  for  the  purpose,  small  suppositories  of 
tannin  and  cacao-butter, 
or  of  nitrate  of  silver 
and  cacao-butter  (tannin 
0.1  gramme,  or  nitrate 
of  silver  0.01  gramme,  in 
each  suppository). 

The  patient  lying  on 
his  back,the  porte-remede 
is  passed,  under  control 
of  the  left  forefinger, 
which  is  in  the  rectum  ; 
the  obturator  is  then  with- 
drawn and  the  suppo- 
sitory ■  pushed  in.  By 
means  of  this  instrument 
it  is  possible  to  deposit 
a  given  amount  of  a 
remedy  in  the  prostatic 
urethra.  If  we  wish  to 
cauterize  the  caput  gallin- 
aginis,  it  is  done  in  the 
same  way,  using  a  sup- 
pository of  double  the 
strength  of  nitrate  of  sil- 
ver (i.e.,  0.02  gramme). 
After      the     suppository 

has  been    deposited  in  the  pars  prostatica,  the 


Fig.  3.— DitteVs  Porte- 
remede. 


in  the  Male.  101 

patient  lies  quiet  a  quarter  of  an  hour.  During 
this  time  the  suppository  has  melted  and  has 
done  its  work.  It  is  then  best  for  the  patient  to 
go  to  bed.  If,  for  the  purpose  of  cauterizing,  the 
stronger  nitrate  of  silver  suppositories  have  been 
used,  the  patient  feels,  some  minutes  later,  a 
severe  vesical  tenesmus  and  a  stinging  pain  at 
the  neck  of  the  bladder.  A  few  hours  later  — 
sometimes,  however,  not  until  the  next  day  — 
bleeding  from  the  urethra  ensues,  sometimes 
slight,  sometimes  profuse.  The  urethra  is  very 
sensitive  and  micturition  painful.  The  patients 
crave  the  horizontal  position  in  bed.  If  the 
heemorrhage  be  profuse,  cold  compresses  must 
be  applied  to  the  perinseum.  After  2  or  3  days 
the  pain  and  desire  to  urinate  diminish,  and  the 
patient  finds  himself  well,  with  the  exception  of 
a  slight  urethral  discharge  which  vanishes  in  a 
day  or  two.  I  have  observed  retention  of  urine, 
profuse  haemorrhage,  and  other  unpleasant  symp- 
toms after  cauterization.  I  therefore  advise  that 
cauterization  be  only  undertaken  when  the  pa- 
tient can  remain  quietly  in  bed  for  from  2  to  5 
days.  In  very  sensitive  patients  I  use  at  first 
only  half  the  dose,  that  is,  half  a  suppository,  and 
if  this  is  well  borne,  the  full  dose  is  then  given. 
A  single  cauterization  is  not  usually  enough  ;  it 
must  be  repeated  at  least  2  or  3  times.  Oftener 
than  once,  however,  or,  at  most,  twice  a  week, 
cauterizing  with  nitrate  of  silver  should  not  be 


102  Neuroses  of  the  Genito-Urinary  System 

(lone.  Good  as  are  the  results  of  cauterization 
by  Lalleraand's  method,  I  prefer  the  porte- 
remede  of  Dittel,  because,  as  already  men- 
tioned, it  is  possible  by  means  of  this  instru- 
ment to  place  accurately  in  the  prostatic  ure- 
thra a  given  amount  of  nitrate  of  silver. 

With  spermatorrhoea  predominating,  when 
pollutions  occur  seldom  or  not  at  all,  faradi- 
zation through  the  rectum  may  be  tried,  as 
described  in  connection  with  enuresis  on  page 
80.  Sometimes  improvement  is  so  far  estab- 
lished that  the  sexual  desire  is  again  aroused, 
erections  take  place,  the  frequent  loss  of  semen 
after  urination  and  defecation  ceases,  and  noc- 
turnal pollutions  occur  instead.  Assuming  that 
spermatorrhoea  consists  in  a  relaxed  condition 
of  the  ejaculatory  ducts.  Trousseau  has  con- 
trived his  compressor  prostatte  for  the  cure  of 
seminal  emissions.  This  is  a  j)lug,  of  the  size 
of  a  pigeon's  egg  to  that  of  a  hen's  egg,  olive- 
shaped  on  one  end,  the  other  end  gradually  tap- 
ering and  fitted  with  a  cross-piece.  The  plug 
is  perforated,  for  the  free  escape  of  flatus,  is 
made  of  hard  rubber,  and  is  kept  in  place  by 
means  of  a  T-bandage.  This  olive-shaped,  some- 
what flattened  plug,  which  is  pushed  into  the 
rectum,  presses  on  the  prostate,  and  should 
press  together  the  dilated  and  relaxed  ejacu- 
latory ducts  and  thereby  bring  about  a  cure 
of    the    spermatorrhoea.       The    instrument    is 


in  the  Male.  103 

usually  very  badly  borne  by  the  patient,  and 
it  works,  as  a  rule,  very  unsatisfactorily. 

When  pollutions  are  kept  up  by  phimosis, 
varicocele,  stone,  and  morbid  processes  in  the 
rectum,  all  these  harmful  influences  must,  of 
course,  be  removed  by  operation. 

3.  The  Secretoky  Neuroses  of  the  gen- 
ito-urinary  system  are  so  often  complicated 
with  the  motor  and  sensory  neuroses  just  de- 
scribed that  they  are  of  secondary  considera- 
tion and  are  only  rarely  observed  as  independent 
conditions.  Since  most  of  the  secretory  neuroses 
have  already  been  considered  in  the  description 
of  certain  motor  and  sensory  neuroses,  a  few 
of  them  only  will  now  be  briefly  mentioned. 

(a)  The  secretory  neuroses  of  the  urinary  sys- 
tem are  confined  to  anomalies  of  the  renal  func- 
tion of  secretion.  We  recognize  these  anomalies 
by  examination  of  the  urine,  which  has  been 
considered  in  detail  under  the  head  of  "  Urine." 
We  found  there  sometimes  polyuria  (urina 
spastica),  sometimes  anuria  (anuria  hyster- 
ica), sometimes  the  secretion  of  an  alkaline  or 
neutral  urine,  without  there  being  at  the  same 
time  a  catarrh  of  the  bladder.  Sometimes  we 
see  the  earthy  phosphates  precipitated  by  heat- 
ing the  urine  and  the  urine  turbid  Qphosphat- 
uria,  Teissier),  sometimes  a  large  amount  of 
indican  is  found  (^glaucuria,  Kletzinski),  some- 
times sugar  and  albumen  temporarily  appear. 


104  Ileuroses  of  the  G-enito-Urinary  System 

(h')  The  secretory  neuroses  of  the  sexual 
system  include  polyspermia  and  aspermia^  al- 
ready described,  and  it  remains  only  to  con- 
sider the  secretory  neuroses  of  the  urethral 
glands.  With  every  sexual  excitement,  as 
soon  as  erection  of  the  penis  has  occurred, 
long  before  the  ejaculation  of  semen  has  taken 
place,  a  clear,  transparent,  viscid  drop,  like 
white  of  e^g^  oozes  from  the  meatus.  This 
clear,  viscid  drop  represents  the  secretion  of 
the  accessory  glands  of  the  urinary  and  geni- 
tal tract,  and  consists  of  the  secretion  of  the 
prostate,  of  Cowper's  glands,  and  of  the  glands 
of  Littre.  Since  the  prostate  is  tlie  largest 
gland  in  this  connection,  it  is  clear  that  the 
mass  of  this  clear  fluid  must  be  prostatic  secre- 
tion. The  object  of  this  secretion  seems  to  be 
to  lubricate  the  urethra  and  thereby  facilitate 
the  discharge  of  the  semen,  which  is  a  fluid  of 
greater  consistency  than  urine.  If  this  clear, 
viscid  fluid  is  secreted  in  greater  amount,  indeed 
continually  and  without  sexual  excitement,  this 
condition  is  called  jorostoiorrAcea.  Gross  was  the 
first  to  describe  this  condition  correctly.  He 
ascribes  as  the  cause  subacute  and  chronic  pros- 
tatitis. Prostatorrhoea  may  be  transient  or  per- 
manent. To  a  slight  degree  it  is  often  found 
after  gonorrhoea,  when  the  yellowish  drop  gradu- 
ally becomes  whitish  and  flocculent  and  finally 
colorless,  watery,  and  slightly  viscid.     The  pa- 


in  the  Male.  105 

tients  usually  say  that  the  gonorrhoea  has  disap- 
peared, but  that  a  certain  moisture  remains. 
Whenever  they  examine  the  penis  and  hold 
apart  the  lips  of  the  meatus  a  drop  of  clear, 
slightly  viscid  fluid  appears,  which  annoys  them. 
This  hypersecretio  urethralis,  moreover,  is  not 
always  so  slight.  Sometimes  it  is  so  copious  that 
the  shirt  of  the  patient  is  constantly  wet  through, 
as  in  acute  gonorrhoea. 

The  cause  of  prostatorrhoea  is  either  mastur- 
bation, sexual  excess,  or,  as  is  usually  the  case, 
gonorrhoea.  Although  other  sources  of  irrita- 
tion at  the  neck  of  the  bladder  and  about  the 
prostate,  such  as  vesical  calculus,  diseases  of  the 
rectum,  etc.,  may  act  as  causes,  yet  gonorrhoea 
furnishes  the  most  and  the  best  cases  of  prosta- 
torrhoea. As  a  rule  the  prostatorrhoea  is  most 
abundant  when  there  has  been  evident  prosta- 
titis, or  when  the  gonorrhoea  was  complicated 
with  cystitis  and  epididymitis.  In  chronic  pros- 
tatitis with  thickening  and  enlargement  of  the 
lobes,  or  hypertrophy  of  the  prostate,  there  is 
also  a  hypersecretion,  yet  it  appears  no  longer 
clear  and  transparent,  but  turbid  from  cell  ele- 
ments (pus  corpuscles  and  prostatic  epithelium), 
milky  and  flocculent  (milchende  Prostata.) 

The  diagnosis  rests  upon  microscopic  exami- 
nation of  the  secretion.  If  the  colorless  or 
whitish  drop  contain  spermatozoa,  spermator- 
rhoea is  present  and  not  prostatorrhoea.     If  the 

5* 


106  Neuroses  of  the  G-enito-Urinary  System 

fluid  contain  no  spermatozoa,  it  may  be  either 
the  semen  of  azoospermia  or  it  is  secretion  from 
the  prostate.  The  drop  is  allowed  to  dry  slowly 
on  the  microscope  slide,  or,  if  a  larger  quantity 
can  be  obtained  for  examination,  it  is  allowed 
to  settle  several  hours  and  the  sediment  is  ex- 
amined. If  the  beautiful  spermatic  crystals  are 
found  (cliaracteristic  of  the  contents  of  the  sem- 
inal vesicles),  the  lluid  is  the  semen  of  a  patient 
affected  with  azoospermia ;  if,  however,  in  the 
slowly  dried  drop  only  the  characteristic  crys- 
tals of  common  salt  are  seen,  the  secretion  in 
question  is  from  the  prostate.  Sometimes  also 
concentric  amyloid  bodies  may  be  discovered, 
which  demonstrate  with  certainty  the  prostatic 
origin  of  the  secretion.  Usually,  however,  in 
the  clear,  viscid  fluid  are  found  only  a  few  cyl- 
indrical epithelial  cells  and  mucous  corpuscles. 

On  examination  with  the  sound  the  urethra  is 
generallj'  found  extremely  sensitive  in  the  pros- 
tatic portion.  Examination  with  the  finger  p^r 
rectum  shows  nothing  abnormal.  Sometimes, 
however,  the  remains  of  a  prostatitis  are  evi- 
dent, such  as  hard  places,  pit-like  depressions, 
asymmetry  of  the  lobes,  etc.  The  urine  is 
clear  and  shows  usually,  on  heating,  the  j^hos- 
phatic  turbidity. 

The  prognosis  in  prostatorrhoea  is  favorable  ; 
yet,  as  in  most  genito-urinary  neuroses,  the 
duration  of  the  treatment  to  complete  recov- 
ery cannot  certainly  be  stated. 


in  the  Male.  107 

The  treatment  of  prostatorrhoea  is  the  same  as 
that  of  seminal  emissions,  and  has  been  minutely 
described.  It  may  be  remarked  that  here  some- 
times faradization  of  the  prostate  per  rectum 
(see  page  40)  has  given  very  good  results. 
Most  to  be  recommended,  however,  is  the  local 
treatment.  The  best  results  have  followed  the 
use  of  astringents  in  solution,  by  means  of  the 
short  urethral  catheter-syringe  (see  page  29). 
Should,  however,  these  methods  not  have  the 
desired  effect,  cauterization  of  the  prostatic 
urethra  by  means  of  Dittel's  porte-rem^de  (see 
page  100}  is  indicated. 


STERILITY   AND   IMPOTENCE. 


ao9) 


STERILITY   AND   IMPOTENCE. 


OUR  knowledge  of  the  potentia  generandi  in 
men  is  of  the  most  recent  date.  Only  a 
few  years  ago  the  opinion  was  held  that  men 
who  were  able  to  perform  the  act  of  coitus  to 
the  satisfaction  of  both  parties  must  also  pos- 
sess procreative  power.  In  case  of  unfruitful 
marriage  all  the  blame  was  usually  thrown  on 
the  wife.  She  was  subjected,  sometimes  to 
operation,  sometimes  to  local  treatment  and 
baths,  for  the  most  part,  however,  without  at- 
taining the  desired  result.  Only  since  the  male 
semen  has  begun  to  be  more  closely  examined 
microscopically,  and  since  the  morbid  processes 
which  lead  to  sterility  in  the  male  have  come  to 
be  better  understood,  has  the  truth  gradually 
become  established  that  potentia  coeundi  in  the 
male  does  not  always  imply  potentia  generandi. 

Potentia  generandi  depends  solely  upon  the 
procreative  po-.ver  of  the  semen,  while  potentia 
coeundi  signifies  the  ability  to  perform  the  act 
of  coitus,  and  is  often  found  unimpaired  in 
cases  where  the  semen  is  absolutely  sterile. 

It  is  a  well-known  fact  that  so-called  impotent 


112  Sterility  and  Impotence. 

men,  who  attempt  coitus  with  flaccid  penis,  are 
still  sometimes  able  to  impregnate  the  female, 
if  they  only  possess  a  normal  semen.  Accusa- 
tions of  paternity  are  not  rare  in  this  connec- 
tion. There  are  also  in  literature  cases  of  impreg- 
nation of  virgins  with  a  wholly  intact,  naiTOW 
hymen,  where  the  ejaculation — in  order  to 
avoid  impregnation  —  had  taken  place  at  the 
vulva  or  its  neighborhood.  Professor  G.  Braun, 
some  time  ago,  published  some  very  interesting- 
cases  of  this  class.  It  is,  moreover,  also  a  well- 
known  fact  that  here  and  there  in  obstetric 
clinics  girls  in  labor  are  met  with,  in  whom 
the  hymen  is  found  entirely  intact.  The  power 
of  procreation  depends,  for  the  most  part,  only 
upon  the  quality  of  the  man's  semen.  As 
proof  of  this  sterile  marriages  are  often  brought 
to  notice,  where  the  husband  is  remarkably  po- 
tent and  fulfils  his  conjugal  duties  perfectly  in 
every  particular ;  yet  the  marriage  remains 
sterile  because  the  semen  of  the  husband  is 
unfruitful. 

In  the  following  pages  the  subject  of  potentia 
generandi  will  first  be  discussed,  and,  later,  that 
of  potentia  coeundi;  finally,  a  few  therapeutic 
hints  will  be  given. 

Since pote7itia  c/enerandi,  as  already  mentioned, 
depends,  for  the  most  part,  on  the  good  or  bad 
condition  of  the  semen,  first  of  all  should  be  con- 
sidered the  male  semen  in  health  and  disease. 


Sterility  and  Impotence.  113 

Male  semeu^  is  a  complex  substance,  and  con- 
sists, under  normal  circumstances,  of  various 
secretions,  namely,  the  secretions  of  the  tes- 
ticles, of  the  seminal  vesicles,  and  of  the  ac- 
cessory glands  of  the  urethra,  especially  the  pros- 
tate, Cowper's  glands,  and  the  mucous  glands 
of  the  urethral  mucous  membrane.  These  se- 
cretions together  form  the  normal  semen  after 
its  ejaculation.  If  one  or  the  other  of  these  se- 
cretions fail,  sterility  may  under  certain  circum- 
stances ensue. 

According  to  Vauquelin  semen  consists  of  10 
per  cent,  solid  matter  and  90  per  cent,  water. 
Of  the  solid  matter  6  per  cent,  consists  of  or- 
ganic constituents,  including  the  spermatozoa, 
3  per  cent,  of  earthy  phosphates,  and  1  per  cent, 
of  alkalies  (chloride  of  sodium).  According  to 
Hoppe-Seyler,  semen  contains  an  albuminous 
substance  called  spermatin,  which,  in  its  reac- 
tions, bears  a  resemblance  to  casein.  The  sper- 
matozoa contain  also  lecithin  in  abundance. 

In  normal  semen,  besides  spermatozoa,  sper- 
matic cells,  epithelium  from  the  jjrostate  and 
urethra  and  molecular  detritus,  so-called  semi- 
nal granules  can  be  distinguished  with  the 
microscope  (Fig.  9).  Before  puberty,  as  well 
as  in  old  age,  semen  contains  no  spermatozoa, 
but  only  seminal  granules,  yet  nevertheless  aged 
men  are  often  met  with,  in  whose  semen  numer- 

'  See  description  of  normal  semen  on  page  83. 


114 


Sterility  and  Impotence. 


ous  spermatozoa  are  still  found.  Sometimes 
these  granules  are  also  massed  in  cylindrical 
forms.  These  have  some  resemblance  to  the 
dark  granular  renal  casts  which  occur  in  the 
urine  in  chronic  Bright's  disease.  The  sperma- 
tic cells  are  the  breeding-places  of  the  sperma- 
tozoa; and,  according  to  KoUiker,  out  of  each 
nucleus  of  a  cell  a  spermatozoon  develops. 


Fig.  9.— Normal  Semen,  a,  L'ving  spermatozoa;  h.  Sperm- 
atic cells;  c,  epithelium  (from  the  prostate  ?);  d,  seminal 
granules.    300  diameters. 

Normal  semen,  sheltered  from  light  and  cold, 
after  48  hours  still  shows  living  spermatozoa 
under  the  microscope.  In  spermatozoa  which 
have  died  gradually  after  ejaculation  the  tail 
is  outstretched,  or,  at  most,  slightly  curved, 
whereas  in  those  that  are  discharged  motion- 


Sterility  and  Impotence.  115 

less,  i.e.^  dead,  the  tail  is  either  rolled  up  in  a 
spiral  or  bent.  Spermatozoa  which  have  been 
killed  by  injurious  secretions  (urine,  acid  vagi- 
nal secretions,  etc.)  very  commonly  show  this 
condition. 

The  motion  of  the  spermatozoa  in  fresh  semen 
is  extremely  lively.  By  whiplike  wriggling  of 
the  tail  the  head  is  urged  forward  and  winds 
its  way,  without  striking  against  other  cells, 
through  the  narrowest  passages  in  the  micro- 
scopic field.  This  migration  of  the  spermatozoa, 
suggestive  of  voluntary  motion,  caused  observ- 
ers in  early  times  to  regard  the  spermatozoa  as 
organized  living  creatures,  as  indicated  by 
the  term,  "  seminal  animalcules  "  [Samenthier- 
chen]. 

Water  soon  checks  the  movements  of  the 
spermatozoa  and  often  causes  the  tails  to  curl 
up  in  a  loop.  Concentrated  solutions  of  salts, 
sugar,  albumen,  urea,  etc.,  may,  however,  revive 
these  motionless  spermatozoa,  so  that  they  re- 
gain their  former  activity.  Animal  secretions 
of  alkaline  reaction  and  moderate  strength  are 
favorable  to  the  vitality  of  the  spermatozoa, 
while  thin  and  acid  secretions,  such  as  urine, 
acid  mucus,  etc.,  have  a  harmful  influence. 
Caustic  potash  and  soda  invigorate  the  sper- 
matozoa ;  on  the  other  hand,  cold  completely 
arrests  their  movements,  as  also  do  solutions  of 
metallic  salts  and  acids. 


116  Sterilitij  and  Impotence. 

The  patliological  changes  of  male  semen  are 
manifold.  The  amount  of  semen  furnished  by 
one  ejaculation  is  very  variable,  and  the  follow- 
ing distinctions  ma}'- be  drawn  :  — 

1.  Aspermia  —  absence  of  semen.  By  this  is 
understood  a  condition  in  which  the  patient, 
whether  in  coitus  or  other  sexual  excitement,  is 
unable  to  ejaculate  semen.  Asperniia  is  either 
absolute  or  relative,  permanent  or  temporary. 
The  absolute  and  permanent  form  of  aspermia 
is  rare.  It  is  either  congenital  or  acquired.  In 
the  first  case  it  concerns  men  who  have  never, 
during  their  whole  lives,  been  able  to  discharge 
semen,  either  in  coitus,  under  sexual  excitement, 
or  as  nocturnal  pollutions. 

Such  a  case  have  I  observed  in  a  man,  40 
years  old,  who,  although  he  had  been  married 
10  years,  had  never  been  able  to  produce  semen. 
His  wife  declared  that  she  had  never  found  her- 
self wet  with  semen  after  coitus.  His  power 
was  pretty  good,  although  not  remarkable.  The 
testicles  were  small,  otherwise  the  genital  or- 
gans were  perfectly  normal.  The  patient  said 
that  during  coitus  he  experiened  the  sensation 
of  ejaculation,  and  felt  a  kind  of  satisfaction, 
although  he  had  never  seen  any  semen.  In  order 
to  prove  whether  or  not  the  semen  regurgitated 
into  the  bladder  during  coitus,  the  urine  passed 
after  the  act  was  examined  for  seminal  constitu- 
ents, but  with  negative  result. 


Sterility  and  Impotence.  117 

Another  case,  that  of  a  single  man,  24  years 
old,  I  have  published  elsewhere  (see  page  87). 

For  this  form  of  permanent  aspermatismus  no 
cause  can  usually  be  shown  ;  the  condition  seems 
to  be  merely  congenital.  The  genitals  in  the 
second  case  appeared  perfectly  normal,  the  penis 
capable  of  erection,  the  testicles  not  small,  and 
yet  no  semen  could  be  produced.  In  the  first 
case  the  testicles  were  smaller,  yet  small  testicles 
are  often  met  with  which  furnish  perfect  semen. 
From  the  size  of  the  testicles  no  conclusions  can 
be  drawn  as  to  the  quantity  and  quality  of  the 
semen.  No  affection  of  the  central  nervous 
system  could  in  either  case  be  demonstrated. 
In  such  cases  we  can  only  assume,  with  Schulz, 
a  non-excitability  of  the  reflex  centre  of  ejacu- 
lation. 

In  absolute  aspermia  no  other  constituent 
of  semen  is  secreted  than  one  or  two  drops  of 
viscid  mucus  which  come  from  the  smaller 
glands  of  the  urethra  and  which  generally  ac- 
company erection.  Ejaculation  is  wholly  want- 
ing, and  from  the  accounts  of  patients  it  must 
be  assumed  that  the  spasmodic  contractions  of 
the  perineal  muscles  which  complete  the  ejacu- 
lation are  entirely  absent. 

More  common  than  congenital  and  permanent 
absence  of  semen  are  the  acquired  forms. 

The  acquired  forms  of  permanent  asper- 
mia  are    usually  brought    about   by  affections 


118  Sterility  and  Impotence. 

of  the  prostate.  Not  infrequently  purulent 
lobar  prostatitis  or  suppuration  of  the  whole 
})rostate  lias  jDreceded.  In  the  acquired  form 
of  permanent  aspermia,  both  ejaculatory  ducts 
must  have  become  occluded  and  the  glan- 
dular tissue  of  the  prostate  itself  have  been  for 
the  most  part  destroyed.  Tlie  occlusion  of  one 
duct  only  sometimes  causes  a  perceptible  dimi- 
nution in  the  amount  of  semen,  but  usually  it 
is  not  noticeable. 

A  man  from  Roumania,  about  40  years  old, 
once  consulted  me  for  trouble  of  this  kind.  He 
had  formerly  cohabited  in  an  entirely  normal 
manner  ;  but  some  years  previously  he  had  had 
a  severe  illness,  with  retention  of  urine  and  pro- 
fuse suppuration  in  the  peringeum,  after  gonor- 
rhoea, and  since  that  time  he  had  never  been  able 
to  discharge  semen  in  coitus.  He  said  that  at  the 
conclusion  of  coitus  he  experienced  a  sort  of 
satisfaction,  although  no  ejaculation  took  place. 

On  examination  of  the  genital  tract  I  found 
the  urethra  slightly  contracted  in  the  bulbous 
portion.  The  perinseuni  showed  a  deep,  re- 
tracted scar,  where,  apparently,  after  an  oper- 
ation, a  great  deal  of  pus  had  been  discharged, 
in  place  of  the  prostate  there  was  felt,  jjer  rec- 
tum, a  small  flattened  nodule,  scarcely  the  size 
of  a  pigeon's  egg,  and  the  whole  anterior  wall 
of  the  rectum  was  involved  in  the  cicatricial 
contraction. 


Sterility  and  Impotence.  119 

m  view  of  this  condition  there  is  scarcely 
a  doubt  that  aspermia  had  here  been  brought 
about  by  obliteration  of  the  ejaculatory  ducts 
and  suppuration  of  the  prostate. 

Although  the  moderate  stricture  could  be 
easily  dilated,  no  further  progress  was  made 
toward  the  secretion  of  semen. 

A  second  case,  a  merchant  here  in  Vienna, 
31  years  old,  likewise  consulted  me  on  account 
of  aspermia.  He  was  married,  but  childless. 
Formerly  he  was  able  to  accomplish  the  act 
of  coitus  in  a  normal  manner,  but  within  a  year 
no  semen  could  be  made  to  appear  even  with 
forcible  straining.  Pollutions  had  also  entirely 
ceased  within  this  time.  At  the  same  time  the 
patient  complained  of  frequent  and  scalding 
micturition. 

The  patient  was  of  feeble  build,  had  a  hoarse 
voice,  and  had  already  suffered  years  with  catarrh 
of  the  lungs.  Physical  examination  showed  dul- 
ness  at  the  apices  of  the  lungs.  The  patient 
yearly  visited  the  health  resort  Roznau.  The 
urine  contained  pus  and  showed  the  character- 
istics of  catarrh  of  the  bladder.  The  sound 
passed  with  ease  as  far  as  the  prostate,  but  could 
only  be  introduced  into  the  bladder  with  great 
difficulty  and  pain.  Per  rectum  a  hard,  nodu- 
lar, immovable  tumor,  as  large  as  the  fist,  was 
found. 

In  this  case  it  must  be  assumed  that  tubercu- 


120  SterUlty  and  Impotence. 

losis  of  the  prostate,  which  had  here  grown  to 
an  unusually  developed,  indurated  infiltration, 
had  rendered  the  ejaculatory  ducts  impervious 
and  the  prostate  incapacitated. 

Beside  these  forms  there  is  a  temporary  asper- 
mia,  with  a  comparatively  normal  condition  of 
the  sexual  ap2)aratus.  This  form  of  aspermia 
sets  in  suddenl}-,  lasts  a  few  weeks  or  months, 
and  then  vanishes  as  suddenly  as  it  came. 

Persons  thus  affected  are  generally  of  a  very 
nervous  temperament.  Either  they  have  been 
nervous  from  birth  or  have  become  so  through 
excesses  in  venery,  masturbation,  or  frequent  at- 
tacks of  gonorrhcea.  In  the  first  case  it  is  usually 
a  certain  anxiety,  a  dread  of  failure  oi  the  act 
of  intercourse,  which  makes  the  patient  some- 
times impotent,  sometimes  asperraous ;  in  the 
last  case,  however,  the  gonorrhceal  process  ap- 
pears to  have  been,  in  fact,  the  immediate  cause 
of  the  nervous  disturbances  in  the  sexual  system. 
These  patients  are  usually  aspermous  in  coitus, 
yet  not  infrequently  suffer  with  pollutions. 

Sometimes  such  cases  occur  after  prostatitis, 
after  infiamraation  of  the  testicles,  and  catarrh 
at  the  neck  of  the  bladder,  following  gonorrhcea. 
Here  a  reflex  neurosis,  proceeding  from  the 
prostate,  is  generally  concerned,  which  com- 
monly yields  to  appropriate  local  treatment. 

Relative  aspermia,  it  must  be  admitted,  is 
especially  rare.     Here  we  have  to  do  with  cases 


Sterility  and  Impotence.  121 

in  which  the  semen  can  never  be  produced  in 
coitus,  even  when,  with  penis  erect,  the  act  is 
prolonged  until  exhaustion.  As  soon,  however, 
as  the  patient  has  fallen  asleep,  he  has  an  emis- 
sion. 

I  have  had  a  case  of  this  kind  under  observa- 
tion a  whole  year.  The  patient,  an  otherwise 
robust  and  healthy  young  man,  two  years  mar- 
ried, can  accomplish  the  coitus  with  penis  erect, 
yet  he  never  has  an  ejaculation  of  semen  within 
the  vagina ;  but  a  supplementary  discharge  ap- 
pears as  a  pollution  during  sleep.  The  patient 
has  never  had  any  sexual  disease,  yet  he  declares 
that  he  experiences  no  voluptuous  sensation  in 
coitus.  He  had  never  attempted  coitus  before 
marriage. 

The  total  absence  of  the  voluptuous  sensation 
in  this  case  makes  it  probable  that  the  causes  of 
this  form  of  relative  aspermatismus  are  to  be 
sought  in  the  nervous  system,  especially  as  the 
genital  organs  and  the  semen  have  been  found 
perfectly  normal.  A  non-excitability  of  the 
centre  of  ejaculation  only  could  here  be  prop- 
erly considered,  since  in  sleep  the  ejaculation 
takes  place  as  a  pollution  in  a  normal  manner. 

There  are  other  forms  of  aspermia  which  are 
best  called  "  false."  Such  is  the  aspermia  in 
cases  of  tight  stricture  and  other  obstructions 
in  the  course  of  the  urethra.  In  such  cases  the 
semen  enters  the  urethra  during  ejaculation,  but, 

6    F 


122  SteriUty  and  Impotence. 

since  it  cannot  pass  tlirougli  the  narrow  stric- 
ture, it  cannot  be  seen,  and  the  patient  appeai-s 
aspermous. 

Since,  during  erection,  the  caput  gallinaginis 
swells  and  the  urethra  is  thereby  closed  poste- 
riorly toward  the  bladder ;  since,  moreover,  the 
stricture  is  made  so  much  the  narrower  by  the 
erection,  so  are  the  pains  of  the  patient,  during 
ejaculation,  easily  explained.  The  semen,  which 
is  compressed  in  the  part  of  the  urethra  behind 
the  stricture,  can  escape  neither  forward  nor 
backward,  hence  the  lancinating  pain  in  the 
perinaaum  during  ejaculation.  The  erection 
now  gradually  subsides  and  with  it  the  swell- 
ing of  the  stricture  and  that  of  the  caput  gal- 
linaginis ;  the  semen  then  usually  flows  back 
into  the  bladder,  where  it  mingles  with  the 
urine,  although  a  small  quantity  may  pass  the 
stricture  and  appear  at  the  orifice  of  the  ure- 
thra. Such  cases  are  of  course  restored  to  the 
normal  condition  by  dilatation  of  the  stricture 
or  removal  of  the  existing  obstruction. 

In  absolute  and  permanent  asjDermia,  it  is  self- 
evident,  impotentia  generandi  is  involved  and 
the  patient  is  sterile. 

In  relative  aspermia  male  sterility  is  likewise 
and  in  so  far  present,  as  the  semen  fails  to  be  dis- 
charged into  the  female  genital  tract.  In  this 
case  an  artificial  impregnation  with  fresh  semen 
discharged  as  a  pollution  may  be  brought  about, 


Sterility  and  Impotence.  123 

which  succeeds  very  well  in  those  cases  in  which 
tlie  semen  is  normal.  In  temporary  aspermia 
the  procreative  power  of  the  patient  depends 
solely  upon  the  quality  of  the  semen,  although, 
as  long  as  the  semen  remains  absent,  there  can 
be  no  talk  of  impregnation.  Sterility  in  cases 
of  urethral  contractions  is,  of  course,  ceteris 
paribus,  cured  by  their  removal. 

2.  Polyspermia. —  This  condition  is  relatively 
rarer  than  aspermia.  By  it  is  understood  a  con- 
siderable increase  in  the  amount  of  semen  dis- 
charged at  a  single  ejaculation,  wliich  may  be 
double  or  even  three  times  the  normal.  If  the 
semen  be  allowed  to  settle  in  a  test-tube,  it  will 
be  found  that  only  the  fluid  is  increased ;  the  cell- 
elements,  among  them  the  spermatozoa,  show, 
in  comparison  with  the  normal  ejaculation,  no 
increase.  Microscopically  the  semen  appears 
normal ;  living  spermatozoa  are  seen  in  large 
numbers. 

A  single  man,  40  years  old,  once  consulted 
me  on  this  account  (see  page  86). 

3.  Oligospermia. —  By  this  is  meant  the  dis- 
charge of  very  small  amounts  of  semen.  The 
amount  evacuated  at  a  single  ejaculation  usually 
varies  from  2  to  6  grammes.  This  condition  is 
found  very  commonly  in  advanced  age ;  like- 
wise after  inflammation  of  the  testicles  and  dis- 
eases of  the  prostate,  such  as  usually  follow 
gonorrhoea.     The  diminution  in  the  amount  of 


124  Sterility  and  Impotence. 

semen  after  these  inflammations  in  the  genital 
tract  is  readily  accounted  for  by  the  deficiency 
of  one  or  another  of  the  secretions  which  col- 
lectively constitute  the  ejaculated  semen.  Thus, 
in  obliteration  of  the  vasa  deferentia  the  semen 
contains  no  longer  the  secretion  of  the  testicles, 
and  after  sperraatitis  or  prostatitis  the  secretion 
of  the  vesiculae  seminales  as  well  as  that  of  the 
prostate  may  be  very  essentially  diminished.  In 
such  cases,  therefore,  oligospermia  is  often  asso- 
ciated with  azoospermia. 

As  alread}^  mentioned,  the  color  of  normal 
semen  is  whitish,  like  that  of  boiled  starch. 
The  dried  stain  of  semen,  which  stiffens  the 
linen  in  a  characteristic  manner,  has,  while 
fresh,  a  light,  grayish-white  color  and  a  nar- 
row, brownish-yellow  border.  In  disease,  espe- 
cially of  the  genital  system,  the  semen  may 
assume  various  shades.     Thus  are  found  :  — 

1.  Semens  of  rt'cZ,  recldish-broum,  and  hrownish- 
yelloto  color.  These  shades  are  generally  due  to 
the  admixture  of  blood.  The  blood  in  these  cases 
arises,  for  the  most  part,  in  the  prostatic  por- 
tion of  the  urethra,  where,  in  the  neighborhood 
of  the  caput  gallinaginis,  a  chronic  urethritis 
has  become  localized.  The  blood  may,  however, 
come  from  the  seminal  vesicles  along  with  the 
semen.  In  the  first  case  the  dried  stains  on  the 
linen  appear  irregularly  colored.  On  the  rusty- 
brown   stains   there    are    usually    small   blood- 


Sterility  and  Impotejice.  125 

specks,  while  in  the  second  case  the  stains  ap- 
pear evenly  colored,  which  indicates  an  intimate 
mixing  of  the  blood  with  the  semen,  as  might 
happen  in  the  seminal  vesicles.  The  brownish- 
yellow  semen  contains,  usually,  blood  and  pus 
in  varying  proportions. 

The  cause  of  bloody  pollutions  is  generally 
gonorrhoea  of  the  posterior  urethra,  the  pars 
prostatica  urethrse.  Not  infrequently  in  the 
fourth  week  of  acute  gonorrhoea  priapism  with 
bloody  pollutions  sets  in.  These  often  last  only 
a  short  time  and  then  disappear  entirely,  yet  they 
sometimes  continue  and  may  persist  many  yeaj  s 
with  undiminished  power,  if  no  check  is  put  on 
them  by  local  treatment.  In  many  cases  the 
bloody  pollutions  do  not  occur  until  later  and  are 
then  a  sequel  of  chronic  gonorrhoea.  The  semen 
may  also  be  bloody  after  masturbation  and  sex- 
ual excesses  in  general,  in  various  diseases  of 
the  prostate  and  seminal  vesicles,  as  well  as  in 
cancerous  degeneration  of  these  organs. 

The  bloody  pollutions  which  sometimes  oc- 
cur in  acute  gonorrhoea  not  infrequently  be- 
come purulent.  In  such  cases  the  color  of  the 
stains  on  the  linen  are  observed  to  gradually 
change  from  red  and  reddish-brown  to  brown- 
ish-yellow and  yellow. 

2.  Yellow  semen.  The  color  of  these  stains 
is  usually  due  to  pus.  In  this  case  the  stains 
have   a  yellowish  or  greenish   color.     The  pus 


126  Sterility  and  Impotence. 

comes,  for  the  most  part,  from  the  urethra  and 
mingles  only  imperfectly  with  the  semen  during 
ejaculation.  These  stains  have  not,  therefore, 
an  even  yellow  color,  but  the  pus  appears  on  the 
dried  seminal  stain  in  smaller  or  larger  patclies, 
irregularly  distributed.  The  pus  may,  however, 
in  inflammation  of  the  seminal  vesicles,  come 
directly  from  these  organs  and  then  the  stains 
appear  evenly  yellow  colored.  Yellow  semen  of 
the  first  kind  is  very  commonly  found  in  chronic 
inflammation  at  the  neck  of  the  bladder,  whereas 
the  evenly  colored  pollutions  appear  more  rarely 
and  are  only  found  well  marked  in  chronic  sper- 
matitis. 

As  for  bloody  pollutions,  so  also  for  purulent 
yellow  semen  the  commonest  setiological  factor 
is  gonorrhoea,  and,  as  already  mentioned,  the 
bloody  pollutions  not  infrequently  become  grad- 
ually transformed  into  the  purulent. 

3.  Wine-colored  or  violet  semen.  The  color  of 
these  pollutions  is,  especially  in  the  dry  state, 
very  characteristic.  It  arises  from  indigo.  The 
freshly  discharged  semen  shows  only  a  grayish- 
violet  tint,  yet  with  the  microscope  it  is  possi- 
ble to  demonstrate  a  large  amount  of  blue  crys- 
talline indigo.  The  wine-red  color  of  this  semen, 
which  is  due  to  the  red  modification  of  the 
indigo,  often  gives  occasion  to  its  confusion 
with  bloody  semen.  A  microscopical  or  chemi- 
cal  test  for  blood  shows  at  once  the  coloring 


Sterility  and  Impotence.  127 

agent  of  the  semen.  Besides,  the  coloring  of 
the  stain  on  the  linen  is  very  even,  which,  with 
bloodj'  semen,  is  very  seldom  the  case. 

Blue  semen  I  have  never  seen,  yet  there  must 
be  such,  even  though  rare.  I  infer  this,  because 
in  my  collection  of  seminal  stains,  discharged 
as  pollutions  and  dried  on  linen,  there  is  a 
specimen  of  grass-green  semen,  the  color  of 
which  is  the  result  of  the  strong  indigo  and 
pus  contained  in  this  semen.  In  semen  contain- 
ing indigo  there  are  usually  living  spermatozoa 
in  normal  numbers.  Such  pollutions  occur  in 
very  nervous  individuals,  especially  after  ven- 
ereal excesses  or  masturbation. 

It  may  also  be  here  remarked  that  the  pollu- 
tions of  jaundiced  persons  show  a  brownish- 
yellow  beer  color. 

Freshly  evacuated,  normal  semen  contains 
living  spermatozoa  in  large  numbers.  The  mo- 
tion of  the  majority  of  the  spermatozoa  is  very 
active,  only  a  few  moving  more  slowly.  A  nor- 
mal, healthy  semen  should  show  in  the  micro- 
scopic field,  with  a  Hartnack  objective  7  and 
ocular  3,  about  100  living  spermatozoa. 

According  to  the  relative  numbers  of  the  sper- 
matozoa two  distinct  pathological  conditions 
are  recognized,  namely,  oligozodspermia  and  azo- 
ospermia. By  oligozoospermia  is  understood  a 
marked  diminution  in  the  number  of  sperma- 
tozoa, while  azoospermia  means  their  total  ab- 


128 


Sterility  and  Impotence. 


sence.  Oligozoospermia  often  occurs  in  ad- 
vanced age,  yet  it  is  found  still  more  frequent- 
ly as  a  congenital  condition  in  youth.  Very 
often  also  it  is  found  that  the  few  spermatozoa 
that  are  secreted  are,  even  in  a  perfectly  fresh 
state,  motionless  and  for  the  most  part  dead 
(Fig.  10).     The  commonest  causes  of  oligozoo- 


FiG.  10.  —  Semen  of  Oligozoospermia.  a,  Living  sperma- 
tozoa; b,  dead  spermatozoa;  c,  pus  corpuscle;  d,  blood 
corpuscles;  e,  seminal  granules.    300 diameters. 

spermia  are  the  gonorrhoeal  inflammations  of  the 
epididjmies  and  spermatic  cords.  By  these  in- 
flammations is  brought  about  sometimes  com- 
plete and  sometimes  only  partial  obliteration  of 
the  vasa  deferentia.  The  passage  of  the  sper- 
matozoa from  the  testicles  to  the  seminal  vesi- 
cles becomes  thereby  very  imperfect  and  scanty. 


Sterility  and  Impotence.  129 

Not  infrequently  are  found  also,  under  the 
microscope,  numerous  pus  corpuscles,  molecu- 
lar detritus,  and  spermatic  crystals. 

Besides  gonorrhoea!  epididymitis,  tuberculosis 
and  new  growths  of  the  testicles  may  cause 
oligozoospermia  as  well  as  azoospermia.  The 
former  condition  may  pass  gradually  into  the 
latter.  Very  rarely  does  the  reverse  take  place, 
although  it  is  possible  in  the  first  year  after  epi- 
didymitis. If  3  or  4  years  have  elapsed  since 
the  epididymitis  an  increase  of  the  spermatozoa 
cannot  be  looked  for. 

Oligozoospermia  involves  sterility  only  when 
the  sparsely  secreted  spermatozoa  are  at  the 
same  time  motionless,  i.e.,  dead.  If  the  sperma- 
tozoa distinctly  show  motion,  there  is  always 
procreative  power,  although  in  a  greatly  dimin- 
ished degree. 

Just  as  common  as  oligozoospermia,  even  more 
common,  is  complete  absence  of  spermatozoa, 
i.e.,  azoospermia.  This  condition  is  always  pres- 
ent before  puberty,  and  sometimes,  although 
rarely,  in  old  age.  But  when  azoospermia  is 
found  in  robust  manhood,  we  have  to  do  either 
with  a  congenital  or  an  acquired  condition.  If 
the  condition  be  congenital  the  testicles  are 
usually  found  to  be  very  small  or  atrophied. 
Sometimes  there  are  also  still  other  congenital 
anomalies  of  the  sexual  organs,  such  as  cryptor- 
chismus,  hypospadias,  and  epispadias.    These  lat- 


130  Sterility  and  Impotence. 

ter  anomalies,  however,  do  not  always  involve 
azoospermia.  Much  more  common  is  the  ac- 
quired form.  Here,  as  a  rule,  there  have  been 
gonorrhoeal  inflammations  of  the  testicles  and 
cords,  with  subsequent  complete  obliteration  of 
the  latter.  In  certain  cases  azoospermia  comes 
about  gradually,  at  first  with  the  occurrence  of 
bloody,  and  then  of  purulent  pollutions,  until  the 
semen  final!}'  becomes  watery  and  the  spermato- 
zoa cease  to  appear.  The  bloody  and  the  purulent 
semens  generally  still  contain  spermatozoa,  but 
they  are  usually  diminished  in  number  and  are 
often  motionless,  and  at  last,  after  repeated  ob- 
servations, they  all  at  once  disappear.  Very 
frequentl}-,  however,  azoospermia  comes  about 
without  previous  bloody  and  purulent  pollu- 
tions. The  intensity  and  frequency  of  the  in- 
flammations of  the  testicles  furnish  no  rule 
for  the  occurrence  of  azoospermia.  There  are 
men  who  have  had  bilateral  epididymitis  6  or 
8  times  and  yet  have  normal  and  fruitful  semen. 
On  the  other  hand,  very  slight  pain  in  the  sper- 
matic cords  and  a  mild,  unilateral  epididymitis 
may  bring  about  azoospermia  ;  the  most  intense 
inflammations  of  the  testicles  and  epididymis 
often  leave  the  semen  unharmed,  while  some- 
times very  slight  inflammatory  processes  in  the 
testicles  and  spermatic  cords  result  in  azoosper- 
mia. Tlie  size  and  density  also  of  the  remain- 
ing induration  of  the  epididymis  do  not  always 


Sterility  and  Impotence.  131 

warrant  an  opinion  as  to  azoospermia,  although 
it  is  of  great  importance,  and,  when  bilateral, 
renders  imperative  an  examination  of  the  semen. 
Although  in  azoospermia  the  semen  discharged 
consists  onlj  of  the  secretions  from  the  vesic- 
ulse  seminales,  the  prostate,  and  the  other  muc- 
ous glands  of  the  urethra,  and  the  secretion  of 
the  testicles  is  wholly  wanting,  yet  there  is  not 
always  a  diminution  in  the  amount  of  the  semen 
in  general.  The  potentia  coeundi,  also,  is  not 
always  in  these  cases  materially  impaired.  There 
are  azoospermous  men  who  have  very  strong 
sexual  desire,  and  who  are  able  to  perform  the  act 
of  coitus  daily  and  even  several  times  a  day. 

The  semen  of  azoospermia,  freshly  discharged, 
exhibits  the  same  peculiarities  of  coagulating 
and  of  smell  as  normal  semen,  which  proves 
that  these  properties  do  not  belong  to  the  se- 
cretion of  the  testicles.  When  azoospermous 
semen  is  allowed  to  settle  in  a  test-tube,  only  a 
very  little  whitish  sediment  is  formed.  This 
consists  mostly  of  epithelium  from  the  seminal 
ducts  and  urethra,  of  seminal  granules,  and  very 
often  also  of  numerous  well-formed  spermatic 
crystals.  Fresh  azoospermous  semen  not  in- 
frequently shows  under  the  microscope  colloid 
masses  which  sometimes  consist  of  oval  kernels, 
and  sometimes  exhibit  the  most  varied  spheroid 
forms  in  a  concentric  arrangement.  Occasion- 
ally, also,  fatty  molecular  detritus  with  small, 


132  Sterility  and  Impotence. 

strongly  refiacting  granules  are  seen.  These 
forms  are  probably  derived  from  the  seminal 
vesicles.  In  fresh  semen  they  often  form  clumps 
of  yellowish  bodies  of  the  size  and  shape  of 
grains  of  sago. 

The  so-called  spermatic  crystals  are  almost  con- 
stantly found  in  azoospermia.  The  thinner  the 
azoospermous  semen  is,  the  sooner  these  crystals 
appear  and  the  larger  they  are.  In  normal 
semen  they  first  appear  after  the  lapse  of  many 
hours,  even  a  day  or  two.  They  may  be  demon- 
strated if  a  drop  is  allowed  to  dry  in  the  air  on 
a  glass  slide.  Under  the  microscope  are  then 
found  imperfectly  crystallized,  colorless,  whet- 
stone-shaped forms,  usually  lying  upon  one 
another  or  arranged  in  rosettes. 

The  chemical  composition  of  the  spermatic 
crystals  is  not  yet  clearly  understood.  Bott- 
cher  considers  them  an  albuminoid  substance, 
Schreiner  a  phosphoric  salt  of  an  organic  base. 
Other  authors  consider  these  crystals  phosphate 
of  magnesia  or  even  ammonio-phosphate  of  mag- 
nesia. The  later  authors  identify  them  with 
the  so-called  crystals  of  Charcot,  and  assume 
that  they  occur  wherever  there  is  a  profuse  se- 
cretion from  mucous  glands.  Fiirbringer  main- 
tains that  these  crystals  are  present  neither  in 
the  secretion  from  the  testicles  nor  in  that  from 
the  vesicula3  seminales,  but  only  in  prostatic  se- 
cretion.    He  also  holds  that  tlie  peculiar  odor 


Sterility  and  Impotence.  133 

of  semen  arises  from  these  crystals.  They  surely 
do  not  belong  to  the  orchitic  secretion,  for  they 
are  found  in  the  most  beautiful  forms,  and  in 
the  greatest  number,  in  the  semen  of  azoosper- 
mia. Since,  moreover,  in  the  secretion  of  pros- 
tatorrhcea  the  concentric  23rostatic  concretions 
are  common,  while  the  spermatic  crystals  are 
only  rarely  found,  and  the  latter  are  almost  con- 
stant in  the  azoospermous  semen,  so  is  the  asser- 
tion not  to  be  disregarded,  that  these  crystals 
belong  also,  at  least  in  part,  to  the  secretion  of 
the  vesiculse  seminales. 

The  spermatic  crystals  are  colorless,  and  be- 
long to  the  rhomboid  system  of  crystals.  Under 
the  microscope  are  found  rhomboid  tablets  and 
rhomboid  prisms.  Sometimes  two  or  more 
rhomboid  prisms  combine  to  form  an  oblique 
cross,  or  a  rosette.  When  the  crystallization 
is  incomplete  these  crystals  take  the  form  of  a 
boat  or  of  a  whetstone,  of  which  the  tapering 
angles  are  bent  in  an  opposite  direction 
(Fig.  6,  page  85). 

The  spermatic  crystals  are  not  a  product  of 
decomposition  of  the  semen,  as  was  formerly 
supposed,  for  they  are  found  in  azoospermous 
semen  a  few  hours  after  ejaculation,  and  in 
normal  semen  immediatel}^  after  drying  on  the 
glass  slide.  That  the  crystals  in  normal  semen 
only  appear  late,  often  not  until  the  second  or 
third  day,  is  explained  by  the  abundance  of  liv- 


134  Sterility  and  Impotence. 

ing  spermatozoa  in  such  semen.  In  a  fluid  full 
of  movement,  such  as  healthy  semen,  crystalliz- 
ation cannot  take  place.  Only  when  the  sper- 
matozoa have  gradually  died  and  the  semen  be- 
comes quiet,  can  the  crystals  form.  Therefore, 
in  normal  semen  they  are  first  found  after  the 
lapse  of  24  hours  ;  in  azoospermia,  on  the  other 
hand,  in  an  hour  or  two. 

Azoospermia  is  usually  a  permanent  affection. 
It  occurs  temporarily  only  a  short  time  after  in- 
flammation of  the  testicles,  and  in  oligozoosper- 
mia  when  coitus  is  too  frequently  practised.  Azo- 
ospermia always  involves  male  sterility,  and  is 
one  of  the  commonest  causes  of  unfruitful  mar- 
riage. 

In  fresh,  healthy  semen  the  spermatozoa  move 
with  great  activity.  If  the  semen,  however,  be 
mixed  with  catarrhal  secretion,  with  acid  urine, 
or  other  harmful  substance,  the  spermatozoa 
move  either  very  sluggishly  or  not  at  all,  even 
when  the  freshly  ejaculated  semen  is  immedi- 
ately placed  under  the  microscope.  During  in- 
flammation of  the  testicles,  of  the  prostate,  and 
especially  of  the  seminal  vesicles,  motionless 
spermatozoa  are  often  found.  In  chronic  ca- 
tarrh of  the  seminal  vesicles  the  majority  of  the 
spermatozoa,  indeed  sometimes  all  of  them,  are 
found,  on  examination,  to  be  motionless.  The 
catarrhal  secretion,  although  it  has  an  alkaline 
reaction,  seems  to  exert  a  liarmful  influence  on 


Sterility  and  Impotence.  135 

the  spermatozoa.  It  is  usually  observed,  also, 
that  the  number  is  diminished  at  the  same  time. 

Semen  whicli  contains  only  motionless  sperma- 
tozoa is  unfruitful.  Whether  the  motionless 
spermatozoa,  when  they  have  been  discharged 
into  the  female  genital  tract  in  coitus,  ever  re- 
gain their  mobility  is  not  known.  I  can  only 
say  that  in  several  cases  of  unfruitful  marriage 
I  have  found  the  spermatozoa  motionless.  I  am 
forced  to  seek  the  cause  of  sterility  in  this 
abnormal  condition  of  the  semen,  all  the  more 
because  Professor  C.  Braun,  on  examining  the 
wives  of  such  men,  has  found  nothing  abnormal 
about  the  genitals.  Semen,  however,  which, 
with  a  majority  of  the  spermatozoa  motionless, 
still  contains  some  living  ones,  furnishes  an 
analogous  condition  to  that  in  which  the  semen 
contains  only  a  few,  but  living,  spermatozoa 
(oligozodspermia)  ;  it  is  not  absolutely  sterile, 
although  impregnation  can  only  occur  under  the 
most  favorable  conditions. 

Spermatozoa  that  are  dead  when  discharged 
generally  have  bent  or  spirally  twisted  tails,  as 
already  remarked. 

Of  abnormal  and  pathological  fo7'ms  of  sperma- 
tozoa may  be  mentioned :  1,  spermatozoa  with 
large  hydrocephalic  heads  ;  2,  spermatozoa  with 
two  heads ;  and  3,  those  with  two  tails.  These 
occur  only  rarely  and  alone,  mingling  with  nor- 
mally formed  spermatozoa. 


136  Sterility  and  Impotence. 

Among  the  pathological  constituents  of  semen, 
observed  with  the  microscope,  besides  blood  and 
pus  corpuscles  and  epithelium,  is  sometimes 
beautiful  blue  crystalline  indigo  in  large  amount. 
This  occurs  in  corn-flower  blue  flakes  and  scales, 
and  is  found  not  infrequently  in  the  semen  of 
very  nervous  individuals. 

The  secretion  of  the  prostate  and  of  the  acces- 
sory glands  of  the  urethra,  which  is  partly  dis- 
charged with  the  semen  and  partlj''  before  it,  ap- 
pears to  serve  various  purposes.  In  the  first  place 
it  serves  to  dilute  the  semen  in  general,  by 
which  the  free  movements  of  the  spermatozoa 
are  made  possible ;  then  this  secretion  has  also 
probably  the  function  of  preparing  the  urethra 
for  the  reception  of  the  semen.  The  urethra  is, 
as  is  well  known,  in  its  whole  length  to  the 
caput  gallinaginis,  a  canal  which  belongs  as 
well  to  the  sexual  as  to  the  urinary  system.  A 
canal,  however,  which  usually  serves  as  an  out- 
let for  the  acid  urine,  cannot,  without  further 
modification,  also  serve  as  an  outlet  for  the 
alkaline  semen.  The  epithelial  covering  of  the 
urethra,  especially  in  its  physiologically  dilated 
portions, —  for  instance,  the  bulbus  urethrfe,— is 
moistened  with  the  remains  of  urine,  and  these, 
I.e.,  the  acids  of  the  urine  and  the  urea,  act  in- 
juriously on  the  spermatozoa.  In  order,  then, 
to  neutralize  the  urethral  walls,  made  acid  by 
the  urine  adhering  to  them,  and  to  prepare  them 


Sterility  and  Impotence.  137 

for  the  alkaline  semen,  the  secretion  of  the  ac- 
cessory urethral  glands  is  discharged  into  the 
canal  before  the  ejaculatio  seminis,  and,  by 
virtue  of  its  thick,  viscid  consistence,  forms  a 
coating  on  the  walls  of  the  urethra.  This  secre- 
tion, as  is  well  known,  appears  during  erection 
of  the  penis  as  a  clear,  transparent  drop  at  the 
meatus. 

The  treatment  of  male  sterility  is  rarely  ac- 
companied with  favorable  result.  If  the  semen 
is  mixed  with  blood  or  pus,  disease  of  the  caput 
gallinaginis  or  of  the  prostatic  portion  of  the 
urethra  is  usually  involved.  In  most  cases  of 
this  sort  the  blood  and  pus  become  mixed  with 
the  semen  only  at  the  moment  of  ejaculation. 
Here  cauterization  of  the  pars  prostatica  ureth- 
ras almost  always  perfectly  serves  the  purpose. 

I  use  for  this  purpose  a  5  per  cent,  solution  of 
nitrate  of  silver  and  apply  it  by  means  of  my 
urethral  dropper.  Of  this  solution  I  generally 
inject  an  amount  indicated  by  from  3  to  5 
marks  of  the  scale  on  the  piston  of  the  small 
syringe  [6  to  10  minims]  (Fig.  11), 

Alread}^,  after  3  or  4  cauterizations,  which  are 
done  at  intervals  of  3  days,  it  becomes  evident 
that  the  former  bloody  semen  has  regained  its 
normal  condition.  The  cauterization  may  be 
equally  well  carried  out  with  urethral  sup- 
positories of  nitrate  of  silver,  applied  through 
Dittel's  porte-rem^de.     If  the  blood  and  pus, 


138 


Sterility  and  Impotence. 


however,  come  from  within  the  vesiculse  semi- 
nales  evenly  mixed  with  the  semen,  the  cauteri- 
ziition  will  not  accomplish  much. 
Fortunately,  however,  this  is  a 
rare  occurrence.  The  differen- 
tial diagnosis  between  blood  and 
pus  from  the  prostatic  urethra 
and  from  the  vesiculse  semi- 
nales  may  be  generally  established 
B  hy  a    microscopical     comparison 

of  the  urinary  sediment  with 
the  semen.  If,  namely,  the 
urinary  sediment  contain  neither 
blood  nor  pus  corpuscles,  if,  how- 
ever, they  are  found  in  the 
semen,  it  may  be  assumed  that 
they  come  from  the  vesiculse 
seminales. 

Oligozcospermia  is  the  result 
either  of  diminished  functional 
activity  of  the  testicle  or  of 
stenosis  of  the  vasa  deferentia,  a 
condition  which  is  brought  about 
especially  by  epididymitis  and 
funiculitis  spermatica.  There  can 
be  no  thought  of  operative  iuter- 
laanu's  Urethral  fcrencc  with  the  vasa  deferen- 
Dropper.  ^.Capii-tja,  on  accouut  of  the  fineness  of 

iRrv   CtithctGi*'  JB 

Pravaz  syringe. '  their  lumen  ;    nothing   therefore 
remains  but  to  arouse  the  testicles  tliemselves 


Sterility  and  Impotence.  139 

to  increased  secretory  activity,  and  this  is  best 
accomplished  by  direct  faradization  of  these 
organs.  If  the  tissue  of  the  testicles  is  still 
in  a  condition  to  form  spermatozoa  in  large 
numbers,  this  not  infrequently  happens  on 
the  use  of  the  induced  current.  At  the  same 
time  the  increased  semen  formation  acts  as  vis 
a  tergo,  dilating  the  contracted  vasa  deferentia, 
and  the  spermatozoa  may  even  be  permanently 
increased  in  such  semen. 

Not  so  favorable  is  the  result  in  azoospermia. 
Here  we  liave  to  do,  as  a  rule,  either  with  com- 
plete atrophy  of  the  testicles,  or  with  impervi- 
ousness  of  the  vasa  deferentia.  If  there  be  com- 
plete atrophy  of  the  testicles  all  therapeutic 
measures  will  be  powerless.  If  imperviousness 
of  the  vasa  deferentia  be  the  cause  of  the  azoo- 
spermia, faradization  of  the  testicles  may  be 
tried.  If  only  a  plugging  up,  but  not  an  oblit- 
eration of  the  vasa  deferentia  be  present,  in 
single  rare  cases  recovery  may  ensue.  If,  how- 
ever, there  be  complete  obliteration,  this  treat- 
ment will  be  of  no  avail. 

A  favorable  result  then,  as  a  rule,  is  only  to 
be  expected  in  azoospermia  when  it  has  existed 
no  more  than  a  year,  counting  from  a  preceding 
inflammation  of  the  testicle.  If,  however,  the 
azoospermia  be  of  longer  duration,  there  is  noth- 
ing more  to  be  hoped  for  from  therapeutic  means, 
for,  even  if  the  vasa  deferentia  could  be  made 


140  Sterility  and  Impotence. 

pervious,  there  would  have  taken  place  already 
atrophy  of  the  testicle  during  this  long  period 
of  its  loss  of  function.  If  the  epididymes  or 
the  spermatic  cords  feel  infiltrated,  i.e.,  thick- 
ened and  hard,  resorption  by  means  of  inunc- 
tion and  bathing  should  be  attempted. 


By  impotentia  coeundi  is  understood  the  in- 
ability to  accomjDlish  the  act  of  sexual  inter- 
course with  erect  penis.  This  inability  is  some- 
times due  to  the  fact  that  no  erection  at  all  can 
be  brought  about  at  the  time  of  coitus,  and 
sometimes  tha,t  an  erection  takes  place  at  the 
proper  time,  but  it  does  not  last  long  enough  to 
make  it  possible  to  finish  the  act.  In  the  latter 
case  premature  ejaculation  is  usually  the  cause 
of  the  penis  becoming  flaccid  before  the  accom- 
plishment of  coitus.  For  the  better  understand- 
ing of  male  impotence  the  mechanism  of  erection 
of  the  penis  and  the  mechanism  of  ejaculation  of 
the  semen  should  first  be  elucidated. 

According  to  Kolliker  and  Kohlrausch  erections 
come  about  in  the  following  manner  :  ^  — Under 
the  influence  of  the  nervi  erigentes  the  organic 
muscular  fibres  of  the  cavernous  tissue  relax, 
by  which  the  spaces  are  widened  and  prepared 
for  the  reception  of  a  large  quantity  of  blood. 
The  presence  of  this  large  quantity  of  blood  in 

>  See  also  page  34. 


Sterility  and  Impotence.  141 

the  corpora  cavernosa  does  not,  however,  alone 
explain  the  erection,  for  if  the  blood  could  flow 
out  again,  in  a  mass,  as  it  flows  in,  a  perfect 
erection  of  the  penis  would  never  occur.  There 
must,  in  addition,  be  provided  a  contrivance  by 
which  the  blood  poured  into  the  corpora  caver- 
nosa cannot  immediately  flow  out  again,  and 
this  end  is  accomplished  by  the  following  anat- 
omical arrangement. 

At  the  beginning  of  erection  the  muscular 
elements  of  the  corpora  cavernosa  relax  through 
the  influence  of  the  nervi  erigentes.  Thereby 
are  opened  at  the  same  time  the  short  arterial 
branches,  anastomosing  in  the  cavernous  spaces 
—  according  to  Joh.  Miiller,  the  arterise  helici- 
nse  —  and  filling  them  with  blood.  From  the 
corpora  cavernosa  the  blood  returns  partly 
through  veins  which  empty  into  the  vena  dorsa- 
lis  penis,  and  partly  through  those  which  emerge 
from  the  interior  of  the  corpora  cavernosa  by 
means  of  gaps  in  the  cortical  reticulum  on  the 
under  side  of  the  penis.  If,  then,  the  corpora 
cavernosa  are  distended  with  blood,  the  filling 
of  the  cortical  reticulum,  which  forms  the  chief 
receptacle  for  the  blood  poured  into  the  corpora 
cavernosa,  necessarily  exerts  pressure  on  the 
outflowing  veins,  and  the  reflux  of  blood  from 
the  corpora  cavernosa  is  checked.  If  now  the 
relaxation  of  the  corpora  cavernosa,  ^^e.,  the  ac- 
tion of  the  nervi  erigentes,  be  incomplete,  a  suf- 


142  Sterility  and  Impotence. 

ficient  quaiitit}^  of  blood  cannot  enter  the  erec- 
tile tissue  to  exert  pressure  on  the  outgoing 
veins,  and  the  penis  cannot  be  brought  to  a  state 
of  erection. 

The  mechanism  of  erection,  then,  is  under  the 
influence  of  the  nervous  system.  According  to 
Eckhard,  erections  can  be  excited  in  dogs  by 
electrical  stimulation  of  the  brain  as  well  as  of 
the  cord.  In  an  analogous  manner  we  observe 
that  in  men  erections  take  place  through  the  in- 
fluence of  lustful  thoughts  in  the  brain,  as  well 
as  in  certain  forms  of  spinal  disease.  Peripheral 
irritation  also,  applied  to  the  genitals,  causes 
erection.  Thus,  with  a  full  bladder,  erections 
usually  occur  more  easily  and  last  longer  than 
with  an  empty  bladder.  It  is  also  known  that 
during  the  night,  in  the  dorsal  position,  the 
pressure  of  the  viscera  on  the  veins  suffices  to 
excite  powerful  erections.  Also  distention  of 
the  vesiculse  seminales,  such  as  occurs  in  strict 
continence,  gives  rise  to  frequent  erections. 
Constipation,  lithiasis,  diseases  of  the  rectum, 
above  all,  diseases  of  the  prostate,  are  associated 
with  frequent  erections.  Especially  inflamma- 
tory diseases  of  the  prostate  are  not  infre- 
quently the  occasion  of  pr6L)nged  erection  of  the 
penis,  and  even  of  painful  priapism.  Finally, 
it  is  well  known  that  peripheral  stimulation,  as 
applied  in  masturbation  to  the  glans  and  skin 
of  the  penis  and  to  the  testicles,  causes  erection. 


Sterility  and  Impotence.  143 

There  is,  accordingly,  no  doubt  that  peripheral 
irritation  applied  to  the  genitals,  as  well  as  irri- 
table conditions  of  the  prostate,  are  able  to  bring 
about  reflex  erections. 

Regarding  the  excitation  of  erections  by  peri- 
pheral nerve-irritation,  Goltz  has  found  that 
they  are  brought  about  more  promptly  and 
powerfully  when,  according  to  experiments  on 
dogs,  the  cord  is  divided  in  the  lumbar  region. 
He  concludes  from  this  that  there  are  also  inr 
hihitory  nerves  of  erection^  which  proceed  from 
the  brain,  and  which  are  designed  to  check,  to 
a  certain  extent,  the  occurrence  of  erection. 
The  experiment  on  dogs  with  the  severed  lum- 
bar cord  plainly  argues  for  this  supposition. 
Erections  occur  more  promptly  on  peripheral 
nerve  stimulation,  because  with  the  division 
of  the  lumbar  cord  the  inhibitory  nerves  from 
the  brain  have  also  been  severed  and  thereby 
made  powerless.  The  existence  of  inhibitory 
nerves  of  erections  explains  very  well  the  oc- 
currence of  the  psychical  form  of  impotence,  as 
will  be  more  fully  explained  later. 

To  complete  the  subject,  the  mechanism  of 
ejaculation  must  also  be  briefly  considered. 

Under  normal  conditions  the  ejaculation  of 
semen  occurs  only  with  erect  penis.  With  erec- 
tion of  the  corpora  cavernosa  the  caput  gallina- 
ginis  swells  also ;  the  mouths  of  the  ejaculatory 
duets  are  thereby  directed  forwards  toward  the 


144  Sterility  cnul  I.npotence. 

membranous  portion,  and  at  the  same  time  the 
bladder  is  closed  behind.  By  this  process  the 
urethra,  which  ordinarily  serves  only  as  a  canal 
for  the  discharge  of  urine,  is  devoted  to  the  use 
of  the  sexual  system.  That,  with  penis  erect, 
the  bladder  is  closed  by  the  caput  gallinaginis 
appears  clear  from  the  fact  that  it  is  impossible 
to  void  urine  when  the  penis  is  erect,  but  very 
easy  to  discharge  semen.  Also  the  pain,  felt  in 
the  periuceum  daring  the  ejaculation  of  semen 
in  cases  of  tight  stricture,  shows  that  the  passage 
backwards  toward  the  bladder  is  closed  to  the 
semen. 

Before  the  occurrence  of  ejaculation  the 
glands  of  the  urethra  begin  to  secrete,  and 
the  secretion  not  infrequently  appears,  with 
strong  erection,  as  a  viscid,  clear  drop  at  the 
orifice  of  the  urethra.  The  object  of  this  secre- 
tion is  probably,  as  already  mentioned,  to  neu- 
tralize the  urethral  walls,  bathed  in  acid  urine, 
by  means  of  a  ropy,  alkaline  fluid,  and  to  pre- 
pare them  for  the  reception  of  the  semen. 
When,  in  coitus,  the  moment  of  ejaculation 
approaches,  a  spasmodic  sensation  with  volup- 
tuous excitement  is  experienced  in  the  peri- 
najum,  and  the  discharge  of  semen  begins 
through  the  ejaculatory  ducts.  At  the  same 
time  the  prostate  discharges  its  secretion.  Then 
the  semen,  gradually  pouring  from  the  narrow 
ejaculatory  ducts,  is  impelled  forwards,  since  it 


Sterility  and  Impotence.  145 

cannot  go  backwards  on  account  of  the  swell- 
ing of  the  caput  gallinaginis,  and  collects  in 
the  bulbus  urethrse,  the  physiological  excavation 
of  the  urethra.  When  a  large  amount  of  semen 
is  collected  here  and  the  bulb  distended  thereby, 
reflex  spasmodic  contractions  of  the  musculus 
bulbo-cavernosus  are  excited,  and  the  semen 
gushes  from  the  urethra. 

That  the  semen,  in  coitus,  is  not  ejaculated 
directly  from  the  vesiculse  seminales  or  from  the 
testicles,  is  evident  enough  from  the  anatomical 
relations,  especially  from  the  narrowness  of  the 
ejaculatory  ducts,  also  from  the  circumstance 
that  with  frequently  repeated  coitus  the  rela- 
tive number  of  spermatozoa  in  the  ejaculated 
semen  diminishes.  The  spermatozoa  cannot 
quickly  enough,  and  in  proportionate  num- 
bers, pass  from  the  testicles  through  the  vasa 
deferentia  into  the  seminal  vesicles  and  thence 
appear  in  the  ejaculated  semen.  The  wide  bul- 
bous urethra,  therefore,  appears  to  serve  as  a  tem- 
porary reservoir  for  the  semen  before  it  is  ejacu- 
lated, and  the  function  of  the  musculus  bulbo- 
cavernosus  seems  to  be  to  eject  the  semen. 
When  the  function  of  this  muscular  apparatus 
is  impaired,  as  is  commonly  the  case  in  the  para- 
lytic form  of  impotence,  the  semen  is  no  longer 
shot  out  in  ejaculation  with  force  in  a  jet,  but  it 
dribbles  slowly  from  the  meatus,  as  fluid  from  a 
flaccid  tube. 

7    G 


146  Sterility  and  Impotence. 

The  following  forms  of  impotence  are  to  be 
distinguished :  1,  organic  impotence,  which  is 
usually  absolute ;  2,  psychical  impotence,  with 
its  Tariety,  relative  impotence  ;  3,  imjjotence  due 
to  weakness  with  abnormal  nervous  irritability, 
which  culminates  in  premature  ejaculation ;  4, 
the  paralytic  form  of  impotence. 

1.  Organic  Impotence. — In  this  case,  on  ac- 
count of  organic  malformation  and  mutilation, 
or  on  account  of  disease  in  the  immediate  vicin- 
ity of  a  normal  penis,  coitus  cannot  be  per- 
formed. To  this  class  belong  extensive  hypo- 
spadias and  epispadias,  deficiency  or  abnormal 
smallness  of  the  penis,  elephantiasis  and  tumors 
of  the  penis,  deviations  and  curves  of  the  penis 
on  erection  due  to  partial  destruction  of  the  cor- 
pora cavernosa  in  consequence  of  wounds  and 
cavernitis,  finally  swellings  in  the  surrounding 
parts,  such  as  large  hernise  and  scrotal  tumors, 
etc.  Also  general  corpulence,  with  a  very  promi- 
nent, overhanging  belly,  may,  in  many  cases, 
render  coitus  impossible.  With  the  organic 
form  of  impotence  there  may  be  very  strongly 
developed  sexual  desire.  Ejaculation  may  take 
place  in  a  normal  manner,  but  the  insertion  of 
the  penis,  on  account  of  the  organic  changes 
mentioned,  has  become  impossible.  Organic 
impotence  is,  for  the  most  part,  absolute,  and 
only  rarely  accessible  to  therapeutic  measures. 

An  interesting  case  in  this  connection,  which 


Sterility  and  Impotence.  147 

T  have  published  in  another  place,  may  be  here 
briefly  mentioned. 

Adolf  J.,  41  years  old,  employed  here  in  a 
bookstore,  was  originally  baptized  as  a  girl, 
with  the  name  Adolfine,  because  his  genitals, 
affected  with  extreme  hypospadias  and  cleft 
scrotum,  were  at  birth  considered  feminine. 
He  wore  girls'  clothes  until  his  20th  year.  But 
when  later  his  beard  had  begun  to  sprout  and 
his  voice  to  assume  the  masculine  character,  the 
patient  was  subjected  to  a  careful  medical  ex- 
amination and  his  sex  established.  From  this 
time  he  assumed  the  name  of  Adolf,  and  wore 
men's  clothes. 

On  examination,  the  following  condition  was 
found  ;  with  the  thighs  spread  apart,  the  geni- 
tals had  the  appearance  of  a  vulva.  The  small 
scrotum  was  split  into  two  parts.  The  right 
half  was  somewhat  thicker  than  the  left,  and 
contained  a  small  testicle  ;  the  left  none.  The 
urethra  of  the  pars  pendula  and  subpubica  was 
completely  wanting.  The  meatus  was  situ- 
ated in  the  lower  angle  of  the  cleft  scrotum. 
The  penis,  very  small,  was  firmly  adherent  to 
the  right  half  of  the  scrotum,  so  that  when  the 
thighs  were  spread  apart,  there  appeared  the 
cleft  scrotum  with  delicate  rose-red  skin,  like 
the  female  vestibule.  The  glans  penis  was 
closely  joined  to  the  upper  wall  of  the  urethra 
in  the  lower  angle  of  the  cleft  scrotum. 


148  Sterility  and  Impotence. 

The  patient  had  strong  sexual  desire  and  was, 
strange  to  say,  married,  yet,  of  course,  was  un- 
able to  perform  the  act  of  coitus.  He  satisfied 
his  desire  by  friction  of  his  genitals  against  those 
of  his  wife,  whereupon  ejaculation  followed.  On 
erection  half  of  the  scrotum  bulged  out  with  the 
enlargement  of  the  penis. 

This  patient  desired  me  to  make  him,  by 
operation,  a  penis  capable  of  intromission.  I 
attempted  the  operation,  and,  indeed,  succeeded 
in  producing  a  small,  freely  movable  penis, 
which  could  be  partially  inserted,  to  the  great 
joy  of  the  patient. 

2.  Psychical  Impotence. — This  form  of  impo- 
tence is  usually  of  a  temporary  nature.  It  is 
commonly  observed  in  nervous  individuals. 
They  are  either  candidates  for  marriage  in  ad- 
vanced age,  or  persons  who  have  masturbated 
a  great  deal  in  early  youth,  or  those  who  have 
had  gonorrhcEa  complicated  with  prostatitis, 
catarrh  of  the  bladder,  and  inflammation  of  the 
testicles.  In  the  first  case  it  is  usually  a  lack 
of  confidence  in  his  power  to  accomplish  the 
act  that  makes  the  patient  impotent.  These 
men  find  themselves,  on  account  of  a  promise 
of  marriage  contracted,  in  a  great  state  of  ner- 
vous excitement,  and  have  a  dread  of  not  being 
able  to  perform  their  conjugal  duties  in  a  suit- 
able manner.  In  consequence  of  this  nervous 
excitement  the  action  of  the  inhibitory  nerves 


Sterility  and  Impotence.  149 

from  the  brain  is  aggravated  and  the  erection 
fails  at  the  critical  moment.  The  influence  of 
fear  and  dread  on  the  occurrence  of  erection 
may  sometimes  be  studied  on  the  examination 
of  such  patients  with  sounds.  When  they  have 
unfastened  their  clothes  and  have  stretched 
themselves  on  the  table  the  penis  is  seen  gradu- 
ally to  shrink,  grow  smaller,  and  to  move  in  a 
worm-like  manner.  The  corpora  cavernosa  be- 
come smaller  and  harder,  the  diameter  of  the 
penis  in  the  pendulous  portion  is  less  than  that 
of  the  glans.  To  the  touch  the  penis  feels 
cartilaginous,  the  skin  shows  transverse  folds 
due  to  the  contraction  of  the  corpora  caver- 
nosa. These  appearances  can  only  be  ex- 
plained by  spasmodic  contraction  of  those  or- 
ganic muscular  fibres  which  are  embedded  in 
the  trabeculse  of  the  corpora  cavernosa.  This 
contraction  is  a  manifestation  of  the  action  of 
the  inhibitory  nerves  of  erection  stimulated  by 
the  fear  and  dread  of  catheterism.  In  exactly 
the  same  way,  then,  other  purely  psychical  in- 
fluences stimulate  the  action  of  the  inhibitory 
nerves,  and  the  patient  is,  at  such  moments, 
impotent. 

In  case  of  masturbation  there  is  another  fac- 
ior  to  be  taken  into  consideration.  Men  who 
are  not  accustomed  to  normal  coitus,  who  em- 
ploy unnatural  means  for  the  gratification  of 
their  sexual  appetites,   may  not  succeed  in  the 


150  Sterility  and  Impotence. 

performance  of  their  conjugal  duties,  but  still 
may  be  fully  competent  to  culiabit  in  the  usual 
manner  with  prostitutes.  A  failure  in  the 
marriage  bed  so  discourages  these  patients  that, 
after  repeated  attempts,  they  become  incapable 
of  getting  an  erection,  although  powerful  erec- 
tions may  occur  at  other  times. 

It  is  also  a  remarkable  circumstance  that 
sometimes  such  patients,  who  were  formerly  in 
a  high  degree  potent,  become  temporarily  impo- 
tent after  a  gonorrhoea,  especially  when  compli- 
cated with  catarrh  of  the  bladder,  prostatitis, 
or  inflammation  of  the  testicles.  In  these  cases 
the  gonorrhoea  has  apparently  exerted  a  para- 
lyzing influence  on  the  nervous  apparatus  of 
the  prostate. 

The  prostate  contains  in  its  superficial  layers 
lining  the  urethra,  as  well  as  in  its  cortical  lay- 
ers, extensive  nervous  plexi,  interspersed  with 
ganglia,  and  to  this  arrangement  belongs,  among 
other  functions,  that  of  reflexly  exciting  erec- 
tions. The  ordinary  pressure  of  a  metallic  cath- 
eter or  sound  is  not  infrequently  followed  by 
strong  erection  of  the  penis.  Likewise  cauteri- 
zation or  the  application  of  astringents  to  the 
prostatic  urethra  produces  erection.  It  is  also 
well  known  that  tumors  of  the  prostate,  calculi, 
and  especially  inflammations  of  the  prostate,  are 
ve-'y  often  accompanied  by  painful  erections  — 
priapism,  much  against  the  will  of  the  patients. 


Sterility  and  Impotence.  151 

There  is,  then,  scarcely  a  doubt  that  from  the 
prostate  reflex  erections  can  be  produced.  The 
reflexes,  however,  are  transmitted  by  the  nerve 
branches,  and  when  these  latter  have  become 
altered  in  any  way,  e.g.,  by  inflammation,  as  in 
prostatitis,  impotence  following  gonorrhoea  is 
explained. 

All  these  processes,  however,  give  rise,  as  a 
rule,  to  a  transient,  temporary  impotence.  In 
all  cases  psychical  influences  of  the  most  varied 
kind  take  part,  and  only  after  the  gradual  re- 
moval of  these  latter  will  the  patients  again  be- 
come potent.  I  know  of  cases  wdiere,  one  and 
two  years  after  marriage,  the  wife  had  not  been 
defloured ;  later,  however,  the  impotence  passed 
away  gradually  and  the  women  bore  one  child 
after  another. 

Patients  affected  with  psychical  impotence 
usually  have  a  normal  genital  apparatus.  In 
certain  cases,  however,  azoospermia  is  found. 
These  patients,  when  they  lie  alone  in  bed, 
have  very  powerful  erections  —  in  distinction 
from  the  paralytic  form  of  impotence, — yet  as 
soon  as  they  attempt  coitus,  which  they  gener- 
ally approach  with  doubt,  anxiety,  or  fear,  there 
IS  either  no  erection  or  a  very  imperfect  one. 
The  prognosis  of  psychical  impotence  is  usually 
favorable. 

Relative  psychical  impotence  is  that  form  in 
which  the  patient  is  unable  to  perform  the  act 


152  Sterility  and  Impotence. 

of  coitus  with  certain  women  only.  It  is  veiy 
unpleasant  when  the  impotence  is  manifested 
toward  the  patient's  own  wife,  as  is  not  infre- 
quently the  case.  In  such  cases  a  mutual  aver- 
sion generally  plays  an  important  part,  or  at 
least  an  aversion  on  one  side,  especially  of  the 
wife.  In  marriages  which  are  contracted,  not 
from  love  or  mutual  affection,  but  from  material 
interests,  this  form  of  impotence  is  not  infre- 
quently found.  There  are  men  who  can  at  any 
time  and  with  any  woman  perform  the  sexual 
act,  yet  there  is  still  a  large  number  of  men  who 
can  do  it  only  when  the  woman  willingly  yields 
herself.  A  large  contingent  is  furnished  by 
those  individuals  who  are  endowed  with  sensi- 
tive nerves,  such  as  so-called  book-worms,  liter- 
ary men,  and  it  is  no  rare  thing  for  such  intellec- 
tual men  to  play  a  lamentable  role  in  sexual  in- 
tercourse, partly  indeed,  from  natural  awkward- 
ness. 

3.  Impotence  due  to  weaktiess  with  abnormal 
irritability. — This  form  of  impotence  is  always 
distinguished  by  premature  ejaculation.  The 
man  so  affected  enters  upon  coitus  with  penis 
erect.  Just,  however,  as  he  is  about  to  begin 
the  act,  even  before  the  penis  can  be  introduced 
into  the  vagina,  ejaculation  and  immediate  flac- 
cidity  of  the  organ  take  place.  This  form  of 
impotence  with  premature  ejaculation  is  very 
common  with  j^ersons  who  enter  upon   coitus 


Sterility  and  Impotence.  153 

under  great  excitement,  furthermore  with  those 
who  have  been  given  for  a  long  time  to  the  vice 
of  masturbation,  and  who  have  frequent  noctur- 
nal emissions.  In  such  cases  the  reflexes  act 
much  too  quickly. 

With  many  men,  affected  with  this  form  of 
impotence,  the  performance  of  coitus  is  an  im- 
possibility, since  on  each  attempt  ejaculation  fol- 
lows too  soon.  In  milder  cases,  however,  the 
first  attempt  only  fails,  while  the  second  and 
third  coitus,  performed  somewhat  later,  succeed 
perfectly. 

If  such  patients  are  examined  with  the  sound, 
the  urethra  is  found  to  be  excessively  sensitive, 
especially  in  the  posterior  portion  —  the  pars 
prostatica.  The  patients  cry  out  and  behave  as 
if  mad  as  the  sound  passes  the  prostate.  In  this 
state  of  things  it  appears  clear  why,  with  the 
hypersesthesia  of  the  urethra,  the  reflexes  which 
go  out  from  it  are  excited  too  quickly. 

The  prognosis  of  this  form  of  impotence  is 
favorable.  It  not  infrequently  disappears  of 
itself. 

4.  The  paralytic  form  of  impotence.  —  This 
differs  from  the  other  forms  in  that  erections 
never  take  place.  Such  patients  not  only  have 
at  coitus  a  flaccid  penis,  but  erections  occur  no 
longer  at  night  or  at  any  other  time.  In  mild 
cases  a  half-erection  may  still  occur,  and  with 
a  large  vagina  coitus  may  be  possible,  but  fre- 


154  Sterility  and  Impotence. 

qnently  the  penis  wilts  even  within  tlie  vagina. 
Ejaculation  also  is  abnormal,  since  it  either  does 
not  occur  at  all  or  else  very  late.  During  ejacu- 
lation the  semen  comes  no  longer  in  jets,  but 
very  slowly  —  gradually  drops,  as  it  were,  from 
the  urethral  orifice.  This  form  of  impotence  is 
observed  not  infrequently  as  a  symptom  of 
chronic  general  diseases,  as  in  diabetes  mellitus, 
in  the  morphine  habit,  in  cerebral  and  spinal  dis- 
eases, and  cachexise  of  various  kinds.  Lesions 
of  the  centres  of  erection  in  the  cord  are  in- 
volved. The  affection  is  not  infrequently  as- 
sociated with  spermatorrhoea. 

On  examination  the  genitals  are  found  with- 
ered and  flaccid.  The  skin  of  the  penis  and  the 
testicles  is  only  slightly  sensitive,  indeed  even 
aniesthetic.  The  sensitiveness  of  the  urethra  is 
much  diminished :  the  sound  passes  with  ease 
and  without  pain  into  the  bladder.  Not  infre- 
quently the  skin  of  the  thigh  and  in  the  vicin- 
ity of  the  genitals  is  found  much  more  sensitive 
to  the  electric  current  than  that  of  the  penis  and 
scrotum. 

The  immediate  cause  of  this  form  of  impo- 
tence is  not  always  clear.  A  large  proportion  of 
the  cases  is  furnished  by  masturbators,  and  prof- 
ligates who  cannot  desist  from  their  practices. 

The  prognosis  is  doubtfuL  In  young  persons 
in  whom  the  power  of  erection  is  not  wholly 
lost,  improvement   and  even  recovery  may  be 


Sterility  and  Impotence.  155 

attained  ;  in  older  patients,  however,  restoration 
of  power  is  scarcely  to  be  expected. 

The  treatment  of  impotence  varies  according 
to  the  different  forms  of  the  affection. 

In  organic  impotence,  as  a  rule,  improvement 
or  relief  can  be  obtained  only  by  surgical  means. 
In  hypospadias  and  epispadias,  by  plastic  op- 
erations, improvement  of  the  condition  may  be 
brought  about  in  so  far  as  a  small,  freely  mov- 
able penis  capable  of  intromission  can  be  formed. 
In  the  case  of  tumors  and  elephantiasis  of  the 
penis,  the  former  must  be  removed  as  well  as 
the  hyper trophied  integument  in  the  latter,  at 
least  in  part.  With  infiltration  in  the  corpora 
cavernosa,  causing  distortion  of  the  erect  penis, 
the  endeavor  must  be  made  to  bring  about  res- 
orption of  the  infiltration.  If  syphilis  is  in- 
volved, antisyphilitic  treatment  with  iodine  and 
mercury  will  have  a  favorable  influence.  In 
traumatic  cavernitis,  or  in  advanced  age,  a  re- 
storation of  the  destroyed  reticular  structure  of 
corpora  cavernosa  is  inconceivable.  Yet  even 
here  iodine,  local  applications  for  the  promotion 
of  absorption,  compression  by  means  of  strips 
of  sticking-plaster,  and  lukewarm  douching  may 
be  tried.  The  large  irreducible  hernise  as  well 
as  great  swellings  of  the  testicles,  especially 
hydrocele,  may  be  remedied  by  operation. 

The  psychical  form  of  impotence  not  infre- 
quently   disappears    spontaneously,    when    the 


156  Sterility  and  Impotence. 

mental  distiiibances,  on  which  the  impotence 
depends,  vanish.  Thus  men  may  suddenly 
become  impotent  when  tliose  most  dear  to 
them  have  been  snatched  away  b}'  death,  or 
when  they  have  unexpectedly  lost  their  prop- 
erty. In  these  cases  pain,  grief,  and  misfortune 
have  a  paralyzing  influence  on  the  centres  of 
erection.  When,  however,  in  tlie  course  of 
time  their  circumstances  improve  and  they  be- 
come quieted,  the  impotence  vanishes.  In  such 
cases  the  friendly  advice  of  a  physician,  who 
possesses  the  confidence  of  his  patient,  has  a 
very  favorable  influence. 

Most  commonl}^  however,  this  form  of  impo- 
tence is  found  in  nervous  young  men  who  have 
previously  been  addicted  to  masturbation,  or 
have  had  severe  gonorrhcea.  Nervous  individ- 
uals and  those  who  have  read  books  which  paint 
in  vivid  colors  the  consequences  of  masturbation 
and  sexual  excess,  and  show  them  in  the  worst 
light  —  such  persons  make  up  the  largest  num- 
ber. Quinine,  iron,  cold  water  bathing,  country 
and  especially  mountain  air  and  travel  form  the 
groundwork  of  the  general  treatment.  Much 
more  efficacious,  however,  is  the  local  treat- 
ment. In  these  cases  the  erectile  power  of  the 
penis  is  by  no  means  extinct.  There  is  merely 
a  functional  disturbance,  in  that  the  erections 
always  occur  at  the  wrong  time  and  never  when 
they  are  wished  for.    Local  treatment  must  then 


Sterility  and  Impotence.  157 

have  for  an  object,  in  an  artificial  manner,  by 
means  of  instruments  and  local  applications,  to 
bring  about  erections  at  a  time  when  the  pa- 
tient thinks  an  erection  cannot  take  place.  The 
occurrence  of  an  erection  in  such  an  unexpected 
manner  strengthens  the  self-confidence  and  the 
trust  in  his  own  sexual  power  so  much  that  the 
patient  becomes  very  soon  potent. 

Since,  as  has  already  been  explained  in  detail, 
erections  may  be  excited  from  the  prostate,  so  in 
the  local  treatment  of  impotence  the  prostate 
forms  the  point  of  attack  for  instrumental  mani- 
pulation. The  following  methods  are  to  be 
recommended :  — 

1.  Treatment  with  sounds.  This  consists  in 
the  daily  passage  of  heavy,  metallic  sounds  of 
a  moderate  curve,  usually  from  Charri^re  Nos. 
20  to  30,  with  the  patient  in  the  horizontal  posi- 
tion, the  sounds  being  passed  into  the  bladder, 
and  allowed  to  remain  there  for  from  5  to  10  min- 
utes. With  the  sound  in  the  bladder  it  is  well 
to  keep  the  distal  end  depressed  by  means  of  a 
towel  or  otherwise  so  as  so  increase  the  pressure 
and  tension  on  the  prostatic  urethra.  Here  the 
metallic  pressure  alone  acts  on  the  prostate, 
and  it  not  infrequently  happens  that  erections 
are  excited  thereby  while  the  sound  is  still  in 
the  urethra,  sometimes  after  a  few  days,  in  cer- 
tain cases  even  in  the  course  of  a  few  minutes. 
In  a  similar  manner  acts  — 


158  Sterility  and  Impotence. 

2.  The  Cold  Sound  or  Psychropkor  (see  page 
98).  The  sound  having  been  passed  into  the 
bladder  with  the  patient  in  the  horizontal  posi- 
tion, the  air  is  exhausted  from  the  free  end  of  the 
outflow  tube  with  a  hand  sj-ringe,  and  the  water 
begins  to  flow  through  the  cold  sound  by  siphon 
action.  The  water  flows  through  one  half  of 
the  sound  to  the  vesical  end,  and  from  thence 
back  through  the  other  half  into  the  empty  ves- 
sel. Here  the  metallic  pressure  and  the  temper- 
ature of  the  water  ciiv;ulating  through  the  sound 
act  together  on  the  prostate.  Usually  the  water  is 
used  as  it  is  taken  from  the  water-main,  that  is, 
at  a  temperature  of  from  9°  to  10°  Ri^aumur  [52° 
to  54°  Fahr.].  If  patients  are  ver}^  sensitive  to 
this  temperature  water  of  from  14°  to  16°  Rd- 
aumur  [63°  to  68°  Fahr.]  may  be  used.  Not 
only  cold  but  heat  sometimes  works  remarkably 
well.  In  cases  where  cold  water  has  no  effect, 
warm  water  of  30°  R(^auraur  [100°  Fahr.]  and 
over  may  be  allowed  to  circulate  through  the 
sound.  It  may  be  observed  in  certain  cases 
that  heat  excites  erections  more  quickly  and 
powerfully  than  cold.  Irritation  by  means  of 
heat  exerted  on  the  prostate  through  the  cold 
sound  is  one  of  the  best  means  of  exciting  erec- 
tions. 

3.  The  treatment  of  the  ^:>ars  prostatica  ure- 
three  by  means  of  astringents.  Just  as  heat  and 
mechanical  irritants,  astringents  also  act  on  the 


Sterility  and  Impotence.  159 

prostate  by  exciting  erections.  Even  simple 
irrigation  of  the  posterior  urethra  with  weak 
solutions  of  zinc,  alum,  and  other  agents  not  in- 
frequently causes  erections ;  astringents,  how- 
ever, are  best  used  in  the  form  of  small  urethral 
suppositories,  which  are  placed  in  the  prostatic 
urethra  by  means  of  Dittel's  porte-remede  {see 
page  100).  Tannin  works  well  in  suppositories 
containing,  at  first,  0.05  gramme,  latter  0.1 
gramme. 

Patients  should  retain  the  suppository  about 
half  an  hour,  before  urinating.  On  urinating, 
the  penis  usually  swells  with  a  painful  sensation, 
and,  later,  erections  occur  more  frequently  and 
more  powerfully.  These  urethral  suppositories 
may  be  introduced  every  day,  or  at  least  every 
other  da}^  until  the  erections  have  become 
powerful  and  enduring. 

A  5  per  cent,  solution  of  nitrate  of  silver, 
applied  by  means  of  the  urethral  dropper  (see 
page  138)  acts  in  a  similar  way. 

In  impotence  due  to  weakness  with  abnormal 
nervous  irritability,  which  is  associated  with 
premature  ejaculation,  in  connection  with  cold 
douching  the  cold  sound  and  mild  cauteriza- 
tions of  the  caput  gallinaginis  by  means  of  the 
urethral  dropper  work  especially  well. 

In  the  paralytic  form  of  impotence  the  results 
of  local  treatment  are  not  encouraging,  jet  the 
favorable  effect  of  the  treatment  v/ith  sounds, 


160  Sterility  and  Impotence. 

of  the  cold  sound  and  the  tannin  suppositories, 
may  sometimes  even  here  be  observed.  It  is 
important  to  advise  for  these  patients  complete 
abstinence  for  a  long  time  from  attem[)ts  at 
coitus.  Also  all  other  sexual  excitement  must 
be  strictly  forbidden.  Cold  water  treatment  in 
connection  with  electricity  may  here  accomplish 
excellent  results. 

In  cases  where,  on  ejaculation,  the  semen  is 
not  discharged  in  jets,  but  dribbles  sluggishly 
from  the  urethra,  faradization  of  the  musculus 
bulbo-cavernosus  is  to  be  recommended.  For 
this  purpose  one  pole,  in  the  form  of  a  metallic 
rectal  electrode,  should  be  pushed  into  the 
rectum  and  the  other  pole  placed  on  the  raphe 
of  the  perinoeura.  In  normal,  healthy  men, 
when  the  current  is  increased,  the  perinseum  is 
felt  bulging  out  powerfully  through  the  con- 
traction of  the  muscles,  Avhile  in  the  paralytic 
form  of  impotence  this  phenomenon  occurs  to 
a  very  shght  degree  or  not  at  all.  Faradiza- 
tion, then,  should  be  carried  out  in  the  manner 
described  above  until  a  distinct  and  j)owerful 
contraction  of  the  musculus  bulbo-cavernosus 
is  observed  to  take  place.  In  many  cases,  how- 
ever, local  faradization  also  avails  nothing. 


NOTES. 


Page  27.  "The  expulsion  of  numerous  thick 
and  short  shreds  with  the  very  beginning  of 
micturition,  .  .  ."  The  expulsion  of  similar 
shreds  with  the  end  of  micturition  also  shows 
prostatitis,  the  follicles  of  the  prostate  being 
filled  with  plugs  which  are  only  squeezed  out  by 
the  muscular  contraction  which  expels  the  last 
drops  of  urine. 

Page  28.  ".  .  .  an  ordinary  syringe 
containing  100  grammes  of  fluid,  .  ,  /' 
Ultzmann  later  used  a  syringe  containing  150 
grammes.  This  is  of  some  interest  in  view  of 
differences  of  opinion  as  to  the  amount  of  fluid 
that  it  is  advisable  to  inject  into  the  bladder. 

Page  46.  "The  cause  of  this  spasmodic  strict- 
ure is  generally  a  diseased  condition  of  the  pros- 
tatic portion  ..."  A  stricture  or  other 
source  of  irritation  in  the  anterior  urethra  may 
also,  reflexly,  cause  spasm  of  the  sphincter. 

Page  62  et  seq.  In  paresis  of  the  bladder  or 
any  other  affection  in  which  there  is  a  liability 
to  retention  and  decomposition  of  urine,  also  in 
any  case  requiring  catheterization  or  other  in- 
strumentation or  operation,  urotropin  (cystogen) 
is  a  very  valuable  remedy.  It  is  excreted  by  the 
kidneys,  setting  free  formaldehyde,  by  which  the 
urine  is  sterilized  and  bacteria  promptly  killed, 
u  (161) 


162  Notes. 

By  its  use  much  of  the  danger  of  urinary  fever 
formerly  dreaded  in  this  class  of  cases  is  avoided. 
If  possible  it  should  be  given  for  a  day  or  two 
before  beginning  catheterization.  When,  for  any 
reason,  urotropin  does  not  suit,  salol  should  be 
given  instead. 

Strict  attention  should  be  paid  to  asepsis,  and 
the  importance  of  this  should  be  impressed  upon 
patients  who  catheterize  themselves.  Rubber 
catheters  may  be  boiled,  and  woven  instruments 
boiled  in  a  saturated  solution  of  ammonium 
sulphate,  or  carefully  cleansed  with  soap  and 
water  and  a  carbolic  solution  before  and  after 
using,  or  disinfected  in  a  formaldehyde  sterilizer. 

As  injections  to  replace,  in  part,  the  urine 
drawn  (page  71),  boric  acid  (2  per  cent.)  and 
potassium  permanganate  (1  to  4000)  are  now  more 
used  than  carbolic  acid.  For  cleansing  a  foul 
bladder  we  may  use  normal  salt  solution,  creolin 
(1  to  500),  formalin  (1  to  500),  or  hydrogen  per- 
oxide (3  or  4  volumes),  the  latter  especially  in 
haemorrhage  for  the  purpose  of  disintegrating 
clots. 

Page  95.  In  the  treatment  of  seminal  dis- 
charges, also  of  prostatorrhoea  (page  107)  and  of 
htemospermatism  (pages  137  and  138),  massage 
of  the  seminal  vesicles  or  of  the  prostate,  as  the 
case  may  be,  is  the  most  effectual  remedy  we  now 
have,  and  will  be  explained  in  the  article  that 
follows:    on  "Nervous  Impotence." 


NERVOUS  IMPOTENCE. 


GARDNER  W.  ALLEN,  M.D. 


NERVOUS  IMPOTENCE. 


IMPOTENTIA  coeundi,  so  well  described  by 
Ultzmann,  is  of  such  practical  importance 
as  perhaps  to  warrant  a  further  discussion  of  that 
variety  of  sexual  disability  which  he  attributes  to 
weakness  with  abnormal  nervous  irritability,  com- 
monly known  as  nervous,  or  atonic,  impotence. 
Simple,  uncomplicated  cases  of  psychical  impo- 
tence are  less  common,  but  a  large  psychical  ele- 
ment exists  in  practically  all  cases;  one  of  the 
usual  manifestations  of  this  is  dread  of  failure 
in  coitus,  which  it  is  very  difficult  to  overcome. 
The  subject  is  obscure  and  complex,  and  con- 
ditions vary  much  in  different  cases;  so  that  it 
is  not  easy  to  estimate  the  relative  force  of  the 
various  nervous,  psychical,  and  physical  elements 
in  a  given  individual.  Consideration  will  first  be 
given  to  the  influences  which  tend  to  bring  about 
primarily  a  hyperemia  and  hyperesthesia  of  the 
prostatic  portion  of  the  urethra,  and  secondarily 
the  morbid  nervous  condition,  with  exaggerated 
reflexes,  which  constitutes  the  affection  under 
discussion.  But  very  often,  and  probably  in  all 
the  more  severe  cases,  there  is  an  underlying 
condition,  a  constitutional  weakness  of  the  indi- 
vidual:  neurasthenia. 

(165) 


166  Nervous  Impotence. 


Etiology, 

Sexual  excess  and  masturbation  are  of  impor- 
tance in  the  causation  of  imjootence.  The  latter 
form  of  indulgence  is  common,  and  those  affected 
with  sexual  weakness,  having  often  a  guilty  con- 
science, are  apt  to  attribute  their  trouble  to  that 
cause,  whereas,  unless  the  practice  has  become 
habitual,  it  probably  has  no  great  effect.  The 
greater  mischief  of  self-abuse  as  compared  with 
overindulgence  with  women  is  threefold:  In  the 
first  place,  excess  is  more  easily  fallen  into,  op- 
portunity being  nearly  alwa5's  present.  Secondly, 
it  is  more  demoralizing,  especially  when  persisted 
in  into  adult  age.  Thirdly,  in  persons  of  a  highly 
nervous  organization  and  imaginative  tempera- 
ment, self-abuse  may  lead  to  a  true  perversion  of 
the  sexual  sense. 

Men  having  sufficient  self-control  and  moral 
purpose  to  avoid  actual  masturbation  may  be 
addicted  to  a  practice  sometimes  called  mental 
masturbation;  that  is,  the  habit  of  allowing  the 
mind  to  dwell,  perhaps  for  hours  at  a  time,  upon 
erotic  subjects.  The  sexual  organs  are  thereby 
kept  in  a  state  of  erethism  for  prolonged  periods, 
not  even  experiencing  the  temporary  relief  af- 
forded by  the  orgasm.  The  victim  of  this  vice 
believes  that  so  long  as  he  prevents  ejaculation 
no  harm  is  done;  but  it  is  evident  that  such 
protracted  and  excessive  hyperairaia  must  neces- 
sarily produce  the  same,  or  perhaps  even  worse, 


Nervous  Impotence.  167 

results.  An  analogous  condition  is  that  of  un- 
gratified  sexual  desire  excited  by  intimate  asso- 
ciation with  women,  stopping  short  of  the  act  of 
intercourse.  During  such  interviews  a  constant 
and  intense  excitement  of  the  genital  organs  is 
maintained  without  the  natural  relief  of  coitus. 
The  testicles  on  such  occasions  are  often  painful 
and  sensitive,  and  nocturnal  emissions  may  be- 
come frequent.  The  more  remote  effects  also, 
nervous  and  mental,  may  be  more  harmful  than 
those  of  simple  excess. 

The  local  physical  results  of  these  various  ex- 
cesses consist  in  a  passive  congestion  and  catar- 
rhal condition  of  the  mucous  membrane  of  the 
prostatic  urethra  and  the  veru  montanum  brought 
about  by  more  or  less  continual  sexual  excite- 
ment, with  frequent  and  protracted  erections;  in 
other  words,  frequent  recurrences  of  active  con- 
gestion. There  is  in  many  cases  the  extreme 
degree  of  hypersesthesia  described  on  page  153, 
and  in  the  urine  may  be  found  shreds  containing 
pus-corpuscles,  epithelium,  and  sometimes  sper- 
matozoa. The  condition  here  described  may  be 
brought  about  by  the  extension  of  gonorrhceal 
inflammation  into  the  prostatic  urethra.  In  a 
considerable  number  of  these  cases  of  gonorrhceal 
prostatitis,  and  also  sometimes  in  the  simple  ca- 
tarrhal cases,  the  follicles  or  tubular  glands  of 
the  prostate  are  involved. 

Continence,  if  long  maintained,  is  regarded  by 
many  authorities  as  a  cause  of  sexual  weakness. 


168  Nervous  Impotence. 

but  it  seems  not  nnlikel}'  that  the  mistake  is 
often  made  of  generalizing  from  a  class.  The 
class  in  this  instance  is  composed  of  those  who 
seek  medical  advice.  The  probability  is  that 
healthy,  normal  men — that  is  to  say,  the  vast 
majority  of  men — may  practice  continence  many 
years,  or  indefinitely,  without  any  loss  of  sexual 
power.  On  the  other  hand,  it  is  also,  doubtless, 
true  that  a  certain  proportion,  perhaps  a  large 
proportion,  of  sexual  neurasthenics  are  injured 
morally  and  physically  by  prolonged  continence, 
and  run  a  risk  of  losing  thereby  what  little  sexual 
vigor  they  have;  and  that  the  impotent  who  have 
had  their  power  restored  to  them  by  treatment 
must  use  it,  although  sparingly,  in  order  to  pre- 
serve it. 

Sexual  perversion  is  nearly  always  a  cause  of, 
or  associated  with,  impotence.  The  sexual  appe- 
tite may  be  perverted  in  many  ways,  with  or 
without  inversion  of  sex.  The  impotence  in  these 
cases  is  of  the  psychical  form,  and  manifests 
itself  by  indifference  or  actual  repugnance  for 
women  and  for  normal  intercourse.  That  there 
need  be  no  real  loss  of  erectile  power  is  shown 
by  the  great  excesses  of  which  they  are  often 
capable.  Many  sexual  perverts  are  actually  in- 
sane. In  some  the  abnormal  appetite  is  congenital 
or  is  developed  at  puberty,  or  even  before,  while 
in  others  it  is  acquired  in  the  search  for  novel 
and  stronger  stimiili  for  organs  which  have  al- 
ready begun  to  flag  as  a  result  of  previous  ex- 


Nervous  Impotence.  169 

cesses,  in  this  case  the  perversion  being  a  result, 
rather  than  a  cause,  of  impotence. 

The  subject  of  seminal  losses  is  considered  at 
length  on  pages  81  to  83  and  92  to  103.  True 
spermatorrhoea — that  is,  the  more  or  less  con- 
stant oozing  of  semen — is  believed  by  some  writers 
to  be  a  very  rare  affection,  but  this  is  undoubt- 
edly a  mistaken  view.  Spermatozoa  may  fre- 
quently be  found  in  the  urine  and  in  the  fluid 
exuding  from  the  meatus  at  stool  in  cases  where 
the  possibility  of  error  due  to  a  previous  coitus 
or  emission  can  be  excluded.  In  the  urine  it  is 
common  to  find  the  spermatozoa  not  at  the  bottom 
of  the  glass,  but  in  semitransparent,  floating 
shreds.  The  seminal  vesicles  are  more  or  less 
diseased  in  most  cases  of  spermatorrhoea,  although 
in  some  cases  there  is  probably  merely  a  patulous 
condition  of  the  orifices  of  the  ejaculatory  ducts. 

Spermatorrhoea  and  impotence  are  often  asso- 
ciated together,  and  it  is  not  always  easy  to  de- 
fine accurately  the  relation  they  bear  to  one 
another.  Either  affection  may,  under  different 
circumstances,  be  regarded  as  a  symptom  of  the 
other,  or  both  as  symptoms  of  an  underlying  con- 
dition. It  is  probable,  however,  that  the  impor- 
tance of  this  loss  of  semen  as  a  cause  of  impo- 
tence has  often  been  overrated,  as  the  condition 
is  found  in  cases  where  there  is  no  question  of 
sexual  power,  and,  on  the  other  hand,  it  is  cer- 
tainly true  that  in  many  cases  of  impotence  there 
is  no  spermatorrhoea. 


170  Nervous  Impotence. 

Nocturnal  emissions  (page  83),  although  gen- 
erally physiological,  are  pathological  when  fol- 
lowed 1)y  definite  symptoms.  Diurnal  emissions 
are  more  serious,  and  in  tlie  severer  cases  show  a 
profound  disturhance  of  the  sexual  function.  In 
a  man  so  affected  the  emissions  may  take  place 
on  very  slight  provocation,  with  very  feeble  erec- 
tion or  none  at  all,  and  with  scarcely  any  sen- 
sation. There  may  be  mild  cases,  however,  in 
which  such  emissions  may  occur  rarely  and  as  a 
result,  perhaps,  of  a  temporarily  increased  ex- 
citability, and  in  which  the  symptom  has  less 
significance. 

Prostatorrlicea  (page  104)  is  also  a  somewhat 
common  complication  in  cases  of  impotence.  It 
can  hardly  be  regarded  as  a  cause  of  sexual 
debility,  yet  the  mere  fact  of  the  discharge,  its 
'contemplation  by  the  patient,  the  unpleasant  sen- 
sation of  trickling  along  the  urethra  and  of  moist- 
ure of  the  gians  and  prepuce,  together  with  the 
fear' that  it  is  semen,  produce  an  amount  of  worry 
and  depression  of  spirits  that  are  often  decidedly 
injurious  in  sensitive  persons. 

Seminal  vesiculitis  is  j^resent  in  a  large  propor- 
tion of  these  cases  of  neurasthenia,  and,  unless 
remedied,  will  seriously  retard,  if  not  prevent,  re- 
covery of  sexual  power.  This  inflammation  of  the 
seminal  vesicles  is  generally  chronic  from  the 
beginning,  and  is  secondary  to  inflammation  of 
the  deep  urethra,  either  posterior  gonorrhoea  or 
the    catarrh    resulting    from    congestion    of    the 


Nervous  Impotence.  171 

prostatic  portion  brought  about  by  prolonged  and 
repeated  sexual  excitement.  The  ampulla,  or  di- 
lated and  convoluted  portion  of  the  vas  deferens 
lying  beside  the  vesicle,  is  commonly  involved  in 
the  inflammation. 

There  are  certain  symptoms  which,  while  not 
peculiar  to  disease  of  the  vesicles,  should  direct 
attention  to  these  organs,  and  in  any  case  they 
should  be  carefully  examined  whenever  there  is 
disturbance  of  the  sexual  function.  Not  uncom- 
monly there  is  a  chronic  urethral  discharge,  and 
in  some  cases  irritability  of  the  bladder,  vnth  fre- 
quent micturition  and  tenesmus.  There  may  be 
deficient  erectile  power,  spermatorrhoea,  repeated 
emissions,  and  occasionally  h^mospermatism.  Ve- 
siculitis following  gonorrhoea  is  more  apt  to  cause 
emissions;  when  due  to  excesses  it  is  more  likely 
to  bring  about  spermatorrhoea.  Sexual  disability, 
however,  is  not  always  present  in  vesiculitis.  Sper- 
matic colic,  a  pain  in  the  region  of  the  vesicle 
due  to  occlusion  of  the  duct,  and  sometimes  ac- 
companying ejaculation  during  coitus  or  emission, 
is  an  occasional  symptom;  likewise  neuralgia  of 
the  cord  or  testicle. 

The  prostate  is  not  infrequently  affected  in  these 
cases,  either  in  connection  with  vesiculitis  or  in- 
dependently of  it.  It  is  common  to  find  it  small 
and  soft,  apparently  atrophied,  in  cases  of  impo- 
tence, without  seeming  to  cause  definite  symptoms. 
But  sometimes  it  is  evidently  the  source  of  much 
of  the  patient's  local  distress.     It  may  be  more 


172  Nervous  Impotence. 

or  less  imifomily  enlarged  and  indurated,  or, 
when  groups  of  glands  here  and  there  are  inflamed 
and  swollen,  it  may  have  an  uneven,  nodular  sur- 
face; or  it  may  be  asymmetrical,  one  lobe  being 
apparently  normal  in  size  and  consistency,  the 
other  enlarged  and  very  hard  and  either  smooth 
or  nodular.  Then,  again,  it  may  be  very  small 
and  round  and  as  hard  and  smooth  as  ivory. 
These  variations  from  the  normal,  except  the  soft, 
atrophied  prostate  first  mentioned,  are  all  charac- 
terized by  extreme  sensitiveness  to  the  touch  and 
very  definite  subjective  symptoms,  chiefly  dull 
pain  and  aching,  often  severe,  in  the  region  of 
the  gland  itself  and  in  the  perineum;  also  some- 
times lumbar  pain.  Urinary  symptoms  are  com- 
mon— frequent  and  urgent  micturition  and  in 
many  cases  phosphaturia;  a  mass  of  phosphatic 
material,  sometimes  granular,  2uay  be  discharged 
at  the  end  of  micturition. 

The  diagnosis  of  these  conditions  of  the  pros- 
tate and  vesicles  depends  upon  physical  examina- 
tion. The  vesicles,  or  at  least  their  lower  parts, 
are  within  reach  of  the  forefinger  in  the  rectum, 
though  sometimes  Avith  difficulty.  The  method 
of  examination  will  be  described  in  connection 
Avitli  treatment.  Just  beyond  the  prostate,  lying 
in  the  sulcus  between  it  and  the  bladder  and 
extending  obliquely  outward  and  backward,  toward 
either  side,  are  the  seminal  vesicles,  each  with  its 
vas  deferens  lying  inside  and  parallel  to  it.  When 
normal  they  are  soft  and  scarcely  appreciable  to 


Nervous  Impotence.  173 

the  touch,  sometimes  not  at  all.  But  when  dis- 
eased they  are  plainly  felt.  One  or  both  may  be 
affected;  the  left  seems  to  be  somewhat  more 
commonly  inflamed  than  the  right.  They  may  be 
nodular  and  indurated  or  distended  with  fluid. 
In  the  latter  case  the  vesicle  is  often  closely  at- 
tached to  the  prostate,  seeming  to  form  the  poste- 
rior border  of  the  lobe  on  that  side;  but  with 
care  fluctuation  can  be  detected  and  a  line  of 
demarcation  can  be  made  out  between  them. 
Sometimes  the  vesicles  are  much  enlarged  and 
dilated,  but  not  distended,  and  form  soft,  fluct- 
uating sacs.  In  some  cases,  probably,  the  am- 
pullae are  alone  or  chiefly  affected.  They  may  be 
felt  as  thickened,  sometimes  indurated,  masses 
nearer  the  median  line. 

By  means  of  pressure  the  contents  of  the  vesicle, 
mingled  with  prostatic  secretion,  are  emptied  into 
the  deep  urethra,  and,  if  in  considerable  quantity, 
will  ooze  from  the  meatus,  and  will  in  any  case 
appear  in  the  urine  passed  after  the  operation. 
The  fluid  thus  squeezed  out  varies  in  different 
cases  from  a  thin  liquid  resembling  skimmed 
milk  to  a  thick,  gelatinous  substance,  sometimes 
containing  inspissated  particles,  and  appearing  in 
the  urine  in  the  form  of  clumps  and  shreds.  Mi- 
croscopic examination  of  the  thin  fluid  shows  only 
a  little  epithelium  and  a  few  dead  spermatozoa; 
the  thick  substance  generally  consists  of  masses 
and  bands  of  fibrinous  material,  entangled  in 
which  are  motionless  spermatozoa  and  often  pus- 


174  Nervous  Impotence. 

cells,  with  or  -without  gonococci.  When  normal 
vesicles  are  massaged  nothing  will  appear,  except, 
perhaps,  a  very  slight  turbidity  of  the  urine.  In 
prostatitis  the  fluid  expressed  consists  of  mucus 
and  prostatic  secretion,  and  may  contain  epithe- 
lium, pus,  plugs  and  shreds  from  the  follicles,  and 
granular  phosphates. 

Pathology. 

A  study  of  the  pathology  of  nervous  impotence 
involves  a  consideration  of  the  local  physical  con- 
dition and  of  the  general  nervous  condition.  It 
involves  a  consideration  of  the  extent  to  which 
the  latter  condition  is  dependent  upon  the  former, 
and  of  the  extent  to  which  it  is  to  be  regarded  as 
an  original  weakness  of  the  nervous  system,  act- 
ing, perhaps,  as  a  predisposing  cause,  or,  at  any 
rate,  favoring  the  development  of  the  various 
nervous  and  mental  phenomena,  which  may  be 
grouped  together  under  the  name  of  sexual  neu- 
rasthenia, although  this  term  does  not  always 
imply  impotence.  The  local  nervous  condition 
also  claims  particular  consideration. 

The  primary  local  condition,  resulting  from 
frequent  and  repeated  engorgements  of  the  blood- 
vessels, consists  in  hyperaemia  and  chronic  catar- 
rhal inflammation  of  the  mucous  membrane  of  the 
prostatic  urethra  and  veru  montanum,  with  atony 
of  the  mouths  of  the  ejaculatory  ducts;  and,  in 
many  cases,  with  extension  of  the  inflammation 
into  the  seminal  vesicles  and  the  ampulh-G  of  the 


Nervous  Impotence.  175 

vasa  deferentia,  or  into  the  follicles  of  the  pros- 
tate. Irritability  of  the  nerve-filaments  terminat- 
ing in  the  mucous  membrane — in  other  words, 
hypersesthesia — is  a  natural  consequence.  Yet 
hypersesthesia  is  not  always  present  in  these  cases. 
There  may  be  only  moderate  sensitiveness,  such 
as  might  seem  to  be  normal,  or  there  may  be 
actual  diminution  of  sensitiveness,  amounting 
even  to  anaesthesia;  but  this  generally,  though  not 
always,  in  more  advanced  cases — the  paralytic 
form  of  impotence.  On  the  other  hand,  there  is 
occasionally  found  a  hypersensitive  condition  of 
the  prostatic  urethra  on  passage  of  the  sound  in 
normal  men;  that  is  to  say,  in  cases  where  there 
are  no  symptoms  of  sexual  debility,  nor  even  ap- 
parently of  prostatic  irritation.  It  would  seem, 
then,  that  this  prostatic  hypersesthesia  is  rather 
an  unreliable  guide;  but  it  is  certain  that,  when 
present  in  the  class  of  cases  under  discussion,  it 
is  significant,  and  its  removal  by  treatment  is 
usually  followed  by  marked  improvement. 

In  order  to  trace  the  connection  between  this 
local  physical  condition  and  the  general  and  local 
nervous  condition,  it  is  necessary  to  study  the 
nerve-supply  of  this  region.  From  Ultzmann's 
description  (see  page  11)  it  will  be  seen  that  the 
spinal  and  sympathetic  nerves  are  here  in  the 
closest  connection  with  each  other,  and  that  an 
irritation  applied  to  a  surface  so  richly  supplied 
with  terminal  filaments  from  these  plexi  will 
produce    most    varied    and    far-reaching    results. 


176  Nervous  Impotence. 

These  results  show  themselves  in  a  general  dis- 
turbance of  the  nervous  system, — cerchral,  spinal, 
and  sympathetic, — and  in  the  local  neuroses  of 
the  genito-urinary  tract.  The  general  nervous 
disturbance  may  be  slight,  even  in  severe  cases, 
or  may  be  prominent  and  manifested  1)y  mental 
depression,  insomnia,  lumbar  pain,  twitching  and 
jerking  of  muscles,  palpitation,  nervous  dyspepsia, 
or  other  symptoms  of  a  neurasthenic  type.  The 
local  neuroses  are  of  special  interest  in  a  study  of 
the  pathology  of  impotence,  and  in  this  connec- 
tion a  comprehension  of  the  mechanism  of  erec- 
tion is  essential  (see  pages  34  and  140). 

Thus  it  is  apparent  that  an  irritation  starting 
in  the  prostatic  region  is  transmitted  to  the  neigh- 
boring plexi  and  ganglia,  thence  along  the  sym- 
pathetic and  central  nervous  systems,  and  reflexly 
from  the  brain  and  cord  to  the  vasomotor,  mus- 
culomotor,  and  sensory  nerves  of  the  genito- 
urinary tract.  Weakness  and  degeneration  of  the 
muscles  concerned  in  erection  through  impaired 
innervation  and  imperfect  nutrition;  feeble  and 
transient  erection  due  to  this  muscular  weakness 
and  to  deranged  function  of  the  vasomotor  nerves 
supplying  the  vessels  of  the  corpora  cavernosa,  as 
well  as  to  spasm  of  the  organic  muscular  fibres 
of  the  cavernous  tissue  through  the  influence  of 
the  inhibitory  action  of  the  cerebral  nerves; 
premature  ejaculation  due  to  the  too  quick  trans- 
mission of  impulses  over  hypersensitive  nerves,  to 
irritability  of  the  genito-spinal  centre,  and  to  the 


Nervous  Impotence.  177 

influence  of  mental  emotions;  various  subjective 
sensations  about  the  genitals,  such  as  smarting, 
tickling,  or  itching  of  the  penis,  scrotum,  or 
neighboring  skin;  diminished  sensibility  to  elec- 
trical stimulation — all  these  phenomena  are  there- 
fore accounted  for.  , 

This  disturbance  of  the  nervous  system,  general 
and  local,  is  probably  purely  functional  in  most 
cases,  but  in  the  extreme  cases,  in  which  there  has 
been  great  and  prolonged  excitation  of  the  cord 
with  consequent  exhaustion,  permanent  impair- 
ment through  degeneration  of  the  nerve-tissue  of 
the  spinal  centres  or  of  the  conducting  trunks, 
or  both,  takes  place.  Erection  is  wholly  absent 
or  very  feeble,  and  coitus  impossible  or  extremely 
difficult,  with  retarded  and  dribbling  ejaculation 
or  failure  of  the  orgasm.  These  are  cases  of 
paralytic  impotence. 

It  remains  now  only  to  consider  to  what  extent 
sexual  disorders  are  dependent  upon  an  original 
weakness  or  defect  of  the  nervous  system.  In 
many  cases  doubtless  the  neurasthenic  state  is 
wholly  acquired  in  later  years,  but  very  often, 
perhaps  as  a  rule,  there  is  a  congenital,  probably 
inherited,  neurotic  temperament:  a  predisposition 
or  propensity,  mental  and  nervous,  to  morbid  im- 
pulses. The  nerves  are  more  prone  to  functional 
disturbance  and  degenerative  changes,  and  there 
is  deficient  will-power  and  self-control  and  a  cer- 
tain lack  of  moral  sense  in  sexual  matters,  which, 
however,  is  consistent  with  the  highest  character 


178  Nervous  Impolence. 

in  other  respects.  In  the  minds  of  such  people 
the  sexual  side  of  life  is  magnified  and  assumes 
an  nndue  importance.  The  healthy,  normally 
constituted  boy  acquires  bad  habits  through  igno- 
rance and  evil  association,  easily  rids  himself  of 
them  when  he  learns  better,  and  sutfers  little 
injury,  while  the  congenital  neurasthenic  begins 
early  and  spontaneously  to  brood  over  sexual 
matters,  his  organism  offers  feeble  resistance  to 
abnormal  impulses  and  their  pathological  effects, 
and  he  easily  drifts  into  a  condition  of  confirmed 
sexual  neurasthenia,  often  leading  to  impotence. 

Prognosis. 

In  most  of  these  cases  we  can  look  forward  to 
a  practical  recovery  of  sexual  power;  that  is  to 
say,  the  patient  will  eventually  be  capable  of  nor- 
mal intercourse  under  favorable  circumstances, 
although  it  may  very  likely  be  unsatisfactory  at 
first.  He  will  probably  never  be  as  powerful  in 
this  respect  as  the  more  vigorous  of  normal  men, 
and  will  be  obliged  always  to  shun  excess.  There 
will  be  times  when  he  fears  his  weakness  is  re- 
turning, and  if  in  an  unfavorable  environment 
he  may  even  fail  in  coitus.  But  he  will  learn  by 
experience  not  to  be  discouraged.  The  tide  will 
flood  again,  and  at  a  later  time  he  will  be  sur- 
prised at  his  own  exhibition  of  virility;  in  some 
cases  there  seems  to  be  a  sort  of  periodicity  about 
these  ups  and  downs.     This  is  about  the  experi- 


Nervous  Impotence.  170 

ence  of  the  average  ease  that  does  well.  But  it 
takes  time,  possibly  many  months  or  even  years, 
to  bring  about  this  result.  The  patient's  mental 
attitude  must  undergo  a  change,  and  this  in  many 
instances  is  a  very  slow  process.  Some  cases  do 
much  better;  they  recover  more  rapidly  and  more 
completely;  here  the  trouble  is  chiefly  psychical. 
A  few  do  badly;  they  are  the  cases  of  organic 
change  and  degeneration  in  the  nervous  centres. 
But  even  these  may  improve  in  time,  especially  if 
there  is  some  erectile  power  remaining. 

Other  things  being  equal,  the  prognosis  in  cases 
of  impotence  following  posterior  gonorrhoea  is 
particularly  favorable,  because  there  is  a  more 
definite  inflammation  which  may  be  expected 
to  improve  under  appropriate  treatment,  and 
moreover  the  mental  condition  is  generally  much 
better. 

With  the  same  qualification  the  outlook  is  good 
in  proportion  to  the  youth  of  the  patient.  But 
there  is  a  certain  class  of  older  men  who  are' simply 
weakened  by  years  of  excess,  with  little  nervous 
disturbance,  and  recover  readily  after  a  period  of 
rest. 

Teeatment. 

The  successful  management  of  sexual  impotence 
requires  a  careful  study  of  each  case  and  great 
patience  and  perseverance  in  following  out  the 
different  lines  of  treatment  that  seem  indicated 
from  time  to  time  by  the  varying  conditions  as 


180  Nervous  Impotence. 

they  present  themselves.  The  patient's  mental 
state  should  receive  attention,  and  he  should  be 
occasionally  reassured  by  as  favorable  a  prognosis 
as  can  be  conscientiously  given.  Everything 
tending  to  promote  cheerfulness  and  distract  his 
attention  from  his  condition  should  be  encouraged, 
and  all  contrary  influences,  such  as  reading  med- 
ical books,  withheld.  As  far  as  hygiene  is  con- 
cerned, it  is  hardly  necessary  to  say  that  he  should 
live  the  healthiest  possible  life,  with  abundance 
of  wholesome  food  and  out-door  exercise,  avoiding 
violent  exertion,  especially  horseback-  and  bicycle- 
riding.  He  should  totally  abstain  from  sexual 
indulgence,  and  avoid  everything  tending  to  direct 
the  thoughts  to  sexual  matters;  and  should  be 
very  moderate  in  the  use  of  alcohol,  tobacco,  tea, 
and  coffee. 

The  invigorating  effect  of  cold  water  may  be 
taken  advantage  of  in  sea-bathing,  the  cold  tub- 
bath,  or  the  more  local  application  of  water  by 
means  of  the  sitz-bath,  or  a  cold  shower  allowed 
to  fall  on  the  lumbar  and  sacral  regions  as  well 
as  on  the  genitals.  In  some  cases  alternate  hot 
and  cold  douching  will  be  found  beneficial.  Fric- 
tion with  a  coarse  towel  should  follow. 

Internal  medication  is  apt  to  be  disappointing. 
Tonics,  of  course,  are  to  be  given  when  indicated 
by  the  general  condition,  but  a  majority  of  these 
patients  are  in  good  health,  even  when  there  is 
a  good  deal  of  general  nervous  disturbance  ;  many 
of  the  worst   cases   are   strong   and   robust.      A 


Nervous  Impotence.  181 

placebo  may  have  a  good  moral  effect.  Sedatives 
are  sometimes  useful  in  excitable  persons,  espe- 
cially in  the  earlier  stages,  but  they  should  be 
given  cautiously  and  not  long  continued,  on  ac- 
count of  their  depressing  effect.  Belladonna  works 
satisfactorily  in  some  cases;  or  atropia  sulphate, 
Veo  grain  every  night  for  two  or  three  weeks. 
The  ordinary  aphrodisiacs  are  well  known:  phos- 
phorus, nux  vomica,  damiana,  cantharides,  and 
others  of  less  repute.  They  may  be  tried  late  in 
the  course  of  treatment,  but  their  effect  must  be 
carefully  watched,  and  if  in  any  way,  even  ap- 
parently, unfavorable,  they  should  be  at  once 
stopped.  Phosphorus  and  cantharides  particularly 
must  be  used  with  great  caution  if  at  all;  in  neu- 
rasthenia they  may  have  a  decidedly  bad  effect. 

Probably  all  authorities  agree  with  Ultzmann 
that  local  treatment  is  by  far  the  most  important 
in  the  handling  of  this  class  of  cases.  In  addition 
to  the  direct  benefit  to  congested  and  hyperses- 
thetic  mucous  membranes,  the  imagination  of  the 
patient  is  more  strongly  appealed  to;  and,  other 
things  being  equal,  the  greater  the  psychical  ele- 
ment in  a  given  case,  the  more  the  moral  effect 
of  treatment  will  be  felt.  The  steel  sound  is  the 
most  useful  of  all  instruments  in  the  treatment 
of  impotence.  The  method  of  employing  it  is 
described  on  pages  97  and  157.  Ultzmann  used 
cylindrical  sounds,  but  they  probably  have  no  ad- 
vantage over  the  ordinary  conical  sounds  com- 
monly used  in  this  country,  which,  moreover,  are 


182  Nervous  Impotence. 

more  easil}^  passed.  Some  additional  benefit  may 
be  derived  from  the  cold  sound,  or  psychrophor 
(pages  98  and  158). 

Injections  are  particularly  useful  where  inflam- 
mation of  the  prostatic  uretlira  is  marked.  The 
syringe  described  on  page  28  (large  size)  holds 
about  5  ounces  and  may  be  used  with  any  cathe- 
ter; the  eye  of  the  catheter  should  be  just  beyond 
the  external  sphincter.  In  addition  to  the  sub- 
stances recommended  for  injections  potassium 
permanganate  will  be  found  to  work  well,  begin- 
ning with  a  solution  of  1  to  4000  and  increasing 
the  strength  gradually  to  1  to  2000.  When  there 
is  a  discharge,  two  or  three  S3'ringefuls  should  be 
injected  successively,  so  as  to  thoroughly  cleanse 
the  neck  of  the  bladder,  and  a  syringeful  may  then 
be  left  in  as  long  as  it  can  be  borne  without  dis- 
comfort by  the  patient.  These  injections  may  be 
repeated  about  twice  a  week.  Solutions  of  cor- 
rosive sublimate  (1  to  20,000),  silver  nitrate  (1 
to  2000)  or  of  formalin  (1  to  400)  may  be  used, 
the  latter  especially  where  a  stimulating  effect  is 
desired.  Of  course,  any  other  kind  of  syringe  or 
irrigator  may  be  used,  but  means  should  be  pro- 
vided for  measuring  the  amount  injected,  which 
should  be  from  4  to  6  ounces. 

The  same,  and  in  some  cases  a  better,  result 
is  obtained  by  means  of  instillations  with  the  ure- 
thral dropper  (see  page  137).  Xitrate  of  silver, 
protargol,  and  argentamin  are  well  adapted  for 
use   with   this   instrument,   and   are   particularly 


Nervous  Impotence.  183 

efficacious  in  inflammation  of  the  deep  urethra. 
It  is  doubtful,  however,  if  so  strong  a  solution  of 
silver  nitrate  as  5  per  cent,  should  be  used,  ex- 
cept in  the  absence  of  active  congestion  and  vi^hen 
a  powerful  stimulating  effect  is  called  for.  Or- 
dinarily solutions  of  from  y,  to  2  per  cent,  are 
employed.  It  is  often  the  case  that  injections  will 
have  a  more  decided  effect  if  immediately  pre- 
ceded by  the  passage  of  sounds.  When,  in  cases 
of  catarrhal  or  gonorrhoeal  prostatitis,  the  tubular 
glands  or  follicles  of  the  prostate  are  involved,  a 
large  sound  will  stretch  them  open  so  that  a  med- 
icated solution  can  better  penetrate  them.  A  pros- 
tatic dilator,  such  as  that  of  Kollmann,  is  still 
better  in  these  cases  of  follicular  prostatitis,  inas- 
much as  by  means  of  it  the  prostate  may  be  dilated 
to  any  extent  without  unduly  stretching  other 
parts  of  the  urethra.  Massage  of  the  prostate  in 
addition  to  dilatation  will  materially  aid  in  empty- 
ing the  follicles  and  so  prepare  the  way  for  the 
injection.  Cauterization  of  the  prostate  and  vera 
montanum  by  means  of  the  porte-remede  (page 
100)  is  too  severe  a  remedy  to  be  recoinmended  for 
general  use. 

The  application  of  electricity  is  described  on 
pages  39  to  41,  79  to  81,  and  IgO.  It  often  has 
a  decided  moral  effect  on  the  patient,  and  perhaps 
the  buzzing  of  the  faradic  battery  contributes  to 
this.  Faradization  may  be  carried  out  safely  and 
without  difficulty  by  the  patient  himself  with  the 
rectal  electrode  as  described  on  pages  40  and  80. 


184  Nervous  Impotence. 

It  should  be  applied  daily,  and  continued  two  or 
three  months  or  longer. 

Of  late  years  massage  of  the  seminal  vesicles 
and  prostate,  as  a  result  of  Fuller's  researches,  has 
come  into  quite  common  use  in  the  treatment  of 
these  cases,  and  often  with  the  most  satisfactory 
results.  In  fact,  this  matter  should  be  attended 
to  first  in  most  cases,  as  little  benefit  will  be  de- 
rived from  other  measures  as  long  as  the  vesicles 
and  prostatic  follicles  remain  distended  with  ac- 
cumulated secretions  and  inflammatory  products. 
Massage  of  the  prostate  is  a  simjDle  kneading  proc- 
ess, paying  particular  attention  to  the  indurated 
and  nodular  areas.  In  the  case  of  the  vesicles 
it  is  not  so  easy  unless  they  happen  to  be  more 
accessible  than  usual.  The  treatment  consists  in 
pressure  with  the  end  of  the  forefinger,  reaching 
as  far  up  toward  the  free  end  of  the  vesicle  as 
possible,  then  palpating  it  with  a  sort  of  rotary 
motion  and  stripping  it  down  toward  the  duct, 
the  latter  manipulation  being  especially  effectual 
in  clearing  the  ampulla  of  the  vas  deferens  and 
the  common  duct.  In  this  way  the  abnormal  se- 
cretions are  removed  and  are  not  allowed  to  accu- 
mulate. Sometimes  the  ducts  are  obstructed  by 
inspissated  material  or  by  concretions  called  sym- 
pexia,  and  several  treatments  are  necessary  to  clear 
them. 

The  patient  about  to  be  massaged  should  stand 
with  the  body  bent  over  a  chair  and  the  hands 
resting  on  it,  the  knees  straiglit  and  feet  spread 


Nervous  Im,potence.  185 

apart.  A  moderately  full  bladder  will  bring  the 
vesicles  within  easier  reach  and  so  facilitate  the 
operation,  which  is  also  aided  by  exerting  counter- 
pressure  with  the  free  hand  over  the  inguinal 
region  of  the  side  which  is  being  explored.  It  is 
further  aided,  in  cases  where  the  vesicles  are  dif- 
ficult of  access,  by  placing  the  foot  corresponding 
to  the  examining  hand  on  a  chair  and  bracing 
the  elbow  against  the  knee;  in  this  way  consid- 
erable force  can  be  exerted  by  which  to  overcome 
the  resistance  of  the  perineal  muscles.  The  fore- 
finger is  passed  through  the  anus  and  over  the 
prostate,  which  should  be  examined  and  its  con- 
dition noted  as  to  size,  form,  and  consistency,  and 
then  obliquely  up  as  high  as  possible  on  either 
side  in  search  of  the  vesicles.  These  organs  or 
the  prostate,  or  both,  according  to  indications, 
should  then  be  massaged  in  the  manner  just 
described. 

The  treatment  may  be  repeated  at  intervals  of 
from  four  to  seven  days.  The  effect  on  the  ves- 
icles is  not,  as  a  rule,  immediately  apparent,  al- 
though in  some  cases  marked  improvement,  espe- 
cially in  subjective  symptoms,  is  soon  noticeable. 
On  account  of  the  very  tortuous  and  convoluted 
structure  of  the  vesicles  it  is  impossible  to  empty 
them  at  once  by  pressure,  and  it  is  therefore  gen- 
erally necessary  to  continue  the  treatment  several 
weeks  before  they  are  restored  to  an  approximately 
normal  condition.  This  is  brought  about  by 
keeping  them  as  nearly  empty  as  possible  until 


186  Nervous  Impotence. 

their  muscular  walls  recover  their  tone  and  they 
are  able  to  j)roperly  carry  on  their  functions.  This 
process  is  appreciable  to  the  physician  in  a  gradual 
decrease  of  the  swelling  and  softening  of  the  in- 
duration, until  after  awhile  the  vesicles  apparently 
disappear;  that  is,  they  become  as  difficult  to  feel 
as  in  the  normal  state.  At  the  same  time  the 
sensitiveness  steadily  diminishes  and  the  amount 
of  detritus  expressed  grows  constantly  less  until 
there  is  no  more. 

In  cases  of  indurated  and  nodular  prostate  the 
effect  of  massage  is  sometimes  more  marked  and 
sooner  apparent,  and  such  a  gland  will  not  infre- 
quently soften  down  and  assume  a  normal  con- 
sistency with  surprising  rapidity.  At  the  same 
time  the  greatest  possible  relief  of  local  distress 
is  in  many  cases  experienced.  Occasionally  the 
atrophied  prostate  also  may  undergo  a  consider- 
able change,  increasing  in  size  and  becoming 
firmer  in  consistency. 

In  the  course  of  the  treatment  by  massage  a 
gradual  improvement  in  the  nervous  condition,  or 
a  diminution  in  the  frequency  of  emissions,  or,  in 
general,  an  abatement  of  whatever  symptoms  sec- 
ondary to  the  diseased  state  of  the  prostate  and 
vesicles  have  been  prominent  in  each  particular 
case  may  be  looked  for. 

In  connection  with  massage  or  independently 
of  it,  irrigation  of  the  rectum  with  hot  water  or 
saline  solution  is  of  benefit  in  some  cases.  This 
is  done  by  the  patient  himself,  and  may  be  re- 


Nervous  Impotence.  187 

peated  daily.  The  injections  may  be  given  through 
a  double  or  a  single  tube;  the  latter  has  the  ad- 
vantage that  the  rectum  may  be  distended,  and 
thereby  a  good  deal  of  pressure  brought  to  bear 
on  the  prostate  and  vesicles,  sometimes  causing  a 
discharge  to  appear  at  the  meatus.  When  v^^ell 
distended,  the  rectum  expels  the  water,  and  more 
is  then  injected,  2  or  more  quarts  in  all  being 
used.  The  water  should  be  as  hot  as  can  be  M'ell 
borne  and  placed  in  a  fountain-syringe  or  other 
reservoir,  at  a  height  of  three  or  four  feet.  It 
may  have  both  a  soothing  and  a  stimulating  effect, 
according  to  circumstances.  Where  the  former  is 
desirable, — that  is,  ■  in  the  more  inflammatory 
cases, — the  double  tube  is  better,  avoiding  disten- 
sion of  the  rectum. 

We  may  sum  up  the  subject  of  treatment  by 
reviewing  in  outline  such  a  course  as  might  be 
followed  out  in  an  average  case.  After  hearing 
the  history,  a  few  encouraging  words  will  relieve 
the  patient's  mind,  gain  his  confidence,  and  so 
greatly  aid  our  efforts.  If  he  should  be  in  a 
highly  nervous  and  excitable  condition,  a  sedative 
may  be  required.  The  local  physical  condition 
must  be  ascertained  at  the  outset.  To  begin  with 
we  make  a  rectal  examination,  and,  if  the  condi- 
tion of  the  prostate  or  vesicles  seem  to  require  it, 
enter  upon  a  course  of  treatment  by  massage, 
which  may  or  may  not  be  combined  with  hot 
rectal  irrigations.  Then  attention  should  be 
turned  to  the  urethra.    A  sound  will  show  hyper- 


188  Nervous  Impotence. 

ffsthesia  of  the  prostatic  portion,  and  if  present 
it  will  rapidly  diminish  with  the  regular  passage 
of  sounds.  When  there  is  a  discharge  which  has 
not  ceased  with  the  massage,  irrigation  of  the  neck 
of  the  bladder  with  potassium-permanganate  solu- 
tion or  some  other  mild  antiseptic  is  indicated,  or 
instillations  of  silver  nitrate.  For  a  stimulating 
effect  in  cases  without  hypersesthesia  or  inflamma- 
tion sounds  passed  frequently  and  left  in  a  con- 
siderable time  or  the  psychrophor  may  act  favor- 
ably; and  in  the  more  atonic  cases  instillations  of 
stronger  silver-nitrate  solutions  or  cauterization 
with  urethral  suppositories  may  be  cautiously 
tried.  Electricity  should  be  employed  at  this  time; 
that  is,  after  sounds  and  injections  have  been 
used  a  good  while  without  marked  improvement, 
especially  when  there  is  anaesthesia  of  the  skin  of 
the  genitals  and  weakness  of  the  muscles  con- 
cerned in  erection. 

As  the  subjective  symptoms  improve  and  evi- 
dences of  inflammation  subside,  the  intervals  be- 
tween treatments  may  be  lengthened  until  an  occa- 
sional sound  or  massage,  so  as  to  keep  informed 
of  the  local  condition,  may  be  all  that  is  required. 
The  duration  of  treatment  may  run  on  in  this  way 
for  weeks  and  months,  possibly  two  or  three  years, 
in  cases  where  the  erection  continues  feeble. 
Meanwhile  a  placebo  or  tonic  may  be  given  for 
its  moral  effect,  and  in  certain  cases  an  aphro- 
disiac is  indicated.  As  already  pointed  out,  the 
patient  must  gain  self-confidence  and  must  change 


Nervous  Impotence.  189 

his  mental  attitude,  and  this  takes  time.  Every 
opportunity  must,  of  course,  be  taken  advantage 
of  to  aid  this  process  by  any  influences  which  may 
be  brought  to  bear  on  the  patient.  Hypnotic  sug- 
gestion has  occasionally  accomplished  something, 
but  has  generally  been  disappointing.  These,  of 
course,  are  the  more  unfavorable  cases.  In  the 
milder  forms  a  few  sounds,  perhaps,  with  a  strong 
statement  that  the  condition  is  not  serious  and 
that  recovery  is  certain,  are  sufficient  to  reassure 
the  patient  and  remove  the  mental  doubt  which 
is  often  so  serious  an  obstacle  to  recovery.  Be- 
tween these  two  types  there  is  every  possible  com- 
bination of  symptoms,  and  treatment  must  vary 
with  the  circumstances  in  each  case. 

Having  arrived  at  the  termination  of  active 
treatment,  the  subject  of  sexual  hygiene  sooner 
or  later  demands  attention,  and  it  is  sometimes, 
especially  in  the  younger  patients,  a  delicate  one 
to  handle  on  account  of  moral  and  social  consid- 
erations. The  patient,  after  listening  to  advice, 
commonly  decides  the  question  for  himself.  Un- 
doubtedly in  many  cases,  sexual  poAver  having 
been  recovered,  the  function  must  be  regularly 
exercised  or  relapse  into  the  former  condition  is 
likely.  The  favorable  cases  may  be  encouraged 
to  marry,  but  the  unfavorable  certainly  should  not 
be,  for  the  welfare  of  others,  probably  more  worthy 
of  consideration,  is  involved. 


INDEX. 


Albuminuria,  20,  103 

Alum,  injections  of,  30 

Anuria,  15,  103 

Aphrodisiacs,  42,  181 

Arsenic  in  treatment  of  cystospasm,  52 

Asepsis,  72,  162 

Aspermia,  86,  88,  104,  116 

absolute,  116 

acquired,  117 

cases  of,  87,  116,  118,  119,  121 

congenital,  116 

false,  121 

relative,  120 

sterility  caused  by,  122 
Astringents,  29,  30,  53,  99,  100,  158,  159,  182 
Atropia  in  treatment  of  enuresis,  79 

of  impotence,  181 
Azoospermia,  90,  127 

acquired,  130 

cause  of,  129,  130 

congenital,  129 

microscopical  examination  of  semen  in,  91,  131 

semen  in,  90,  131 

spermatic  crystals  in,  132 

treatment  of,  139 

Baths  in  treatment  of  cystospasm,  52 
enuresis,  78 
paresis  of  bladder,  62 
impotence,  156,  180 
spermatorrhoea,  95 
Belladonna  in  treatment  of  enuresis,  78 
of  impotence,  181 
of  spermatorrhoea,  96 
Bladder,  catarrh  of  (see  Cystitis) 
hypersesthesia  of,  27 
neuralgia  of,  27 

paralysis  or  paresis  of,  53,  161,  162 
paresis  of  detrusors  of,  53 
causes  of,  56 

(191) 


192  Index. 

Bladder,  paresis  of  detrusors  of,  conditions  of  pressure  in,  65 

diagnosis  of,  57,  58 

prognosis  of,  60 

S3'mptonis  of,  55 

treatment     of     (see     Catheterization    and     Elec- 
tricity), 62 

urine  in,  59 
paresis  of  sphincter,  53 

complicated  with  paresis  of  detrusors,  59 
spasm  of  detrusors,  48 

examination  with  the  sound  in,  51 

symptoms  of,  49 

treatment  of,  52 

urine  in,  50 
spasm  of  sphincter,  44 

cause  of,  46,  161 

examination  with  the  sound  in,  47 

mistaken  for  urethral  stricture,  48 

symptoms  of,  44 

treatment  of,  48 
sphincter  of,  27,  44,  53,  76 
Bromide  of  potassium  in  treatment  of  cystospasm,  52 

of  impotence,  39 

of  spermatorrhoea,  96 

Camphor  in  treatment  of  spermatorrhoea,  96 
Cantharides  in  treatment  of  impotence,  42,  181 
Caput  gallinaginis  (see  Veru  Montanum) 
Carbolic-a<'id  injections,  29,  162 
Catarrh  of  bladder  (see  Cystitis) 

of  prostate  ( see  Prostate ) 
Catheterization,  47,  54,  58,  61,  64 

in  treatment  of  paresis  of  bladder,  64,  161 
dangers  of,  65 

precautions  to  be  observed  in,  70,  161,  162 
relation  of,  to  conditions  of  pressure,  65 
Cauterization  of  prostatic  urethra,  42,  48,   100,   137,   159, 

183,  188 
Cold  sound  (see  Psychrophor) 
Continence,  167 

Cystitis  in  paresis  of  bladder  and  following  oatheteriza^ 
tion,  59.  60,  64-70 
result  of  negative  pressure,  68 
Cj-stopyelitis,  60,  65,  67,  68,  70 
Cystospasm  (see  Spasm  of  Bladder) 

Diabetes  insipidus,  13 
niellitus,  14,  16 


Index.  1 9o 

Diminished  sensibility  of  penis  and  urethra  in  impotence, 

31,  37,  41,  154,  175.  177,  188 
Dribbling  of  urine,  43 

Ejaculation,  mechanism  of,  140,  143 
premature,  33,  146,  152,  176 
retarded,  177 
Electricity  in  enuresis,  77,  79,  80 

in  impotence,  37,  40,  160,  183,  188 
in  paresis  of  laladder,  63 
in  pollutions  and  spermatorrhoea,  97 
Emissions  (see  Pollutions) 
Enuresis,  73 

continua,  74 
diurna,  74 
nocturna,  74 

electrical  treatment  of,  79 
etiology  of,  74 
influence  of  age  and  sex,  77 
pathology  of,  76 
treatment  of,  78 
Epididymitis,  90,  128,  130 
Erection,  inhibitory  nerves  of,  36,  143,  176 

mechanism  of,  34,  140,  176 
Erections  in  dogs,  35,  36,  142 
Ergot  in  enuresis,  79 

in  paresis  of  bladder,  62 
in  spermatorrhoea,  97 

Formalin,  162,  182 

Glycosuria,  13,  15,  60,  103 

Gonorrhoea  as  a  cause  of  neuroses,  9,  26,  27 

of  impotence,  150,  151,  167,  179 

of  prostatitis,  183 

of  vesiculitis,  170 

Hsemospermatism,  89,  124,  137,  162,  171 
Hygiene  in  treatment  of  cystospasm,  52 

of  enuresis,  78 

of  impotence,  156,  180 

of  paresis  of  bladder,  62 

of  spermatorrhoea,  95 

Impotence,  31,  140,  146,  163 
etiology,  166 
organic,  31,  146 


101  Index. 


Impotence,  paralytic,  140,  153,  175,  177,  179 
pathoUif^y,  174 
prognosis,  178 
psychiciil,  31,  146,  148,  165 

relative,  32,  146,  151 
treatment,  39,  155,  179 
general,  39,  156,  180 
local,  39,  157,  181 
surgical,  155 
with  abnormal  irritability,  146,  152,  165 
Impotentia  coeinuli  (see  Impotence) 

generandi  (see  Sterility ) 
Incontinence  of  urine,  57,  61,  73 
Indican,  19 
Indigo,  23,  90,  136 
Injections  in  the  bladder,  71,  162 

in  the  prostatic  urethra,  28,  99,  137,  182 
in  the  rectum,  186 
Innervation  of  prostate  and  uterus,  11,  175 
of  sphincter  vesicae,  imperfect,  77 
of  sphincter  ani,  80 
Involuntary  micturition,  8 
Iron  in  treatment  of  cystospasni,  52 
of  impotence,  156 
of  spermatorrhoea,  96 
Ischuria,  61 

Lupulin  in  the  treatment  of  spermatorrhoea,  96 

Massage  of  prostate  and  vesicles,  162,  183,  184 
Masturbation,  19,  33,  92,  148,  153,  154,  166 
Mechanism  of  ejaculation  (see  Ejaculation) 

of  erection  ( see  Erection ) 
Morphine  in  treatment  of  cystospasm,  52 
Motor  neuroses,  25,  43,  81 

Negative  pressure,  68 

Nephritis  following  catheterization,  67,  68,  70 

Nervi  erigentes,  34,  141 

Nervous  impotence,  32,  148,  163 

Neurasthenia,  sexual,  165,  174,  177 

Neuroses,  classification  of,  24 

etiology  of,  7 

general,  176 

local,  176 

motor,  43 

sexual,  81 


Index.  li)5 

Neuroses,  motor,  urinary,  43 
secrefcoiy,  103 
sexual,  104, 
urinary,  103 
sensory,  25 
sexual,  31 
urinary,  25 
urine  in,  12 
Nitrate-of-silver  solutions  in  sterility,  137 
in  impotence,  159,  182 
in  prostatorrhoea,  107 
suppositories  in  spermatorrhoea,  100 
Nux  vomica  in  treatment  of  enuresis,  79 
in  treatment  of  impotence,  181 

Oligospermia,  123 
Oligozoospermia,  127,  128,  138 
Oliguria,  15 
Organic  impotence,  31,  146 

Paralysis  and  paresis  of  bladder  (see  Bladder) 
Pathological  anatomy  in  cases  of  neurosis,  12 
Penis,  malformation  of,  31,  146 
Permanganate  of  potassium,  162,  182 
Phosphates,  17 

alkaline,  18 

earthy,  17,  51.  103,  113 
Phosphaturia,  51,  103,  172 
Phosphorus  in  treatment  of  impotence,  42,  181 
Pollutions,  41,  81,  92 

diurnal  and  nocturnal,  82,  170 

pathological  and  physiological,  83 

treatment,  95 
Polyspermia,  86,  104,  123 
Polyuria,  8,  13,  14,  50,  103 
Porte-remede  of  Dittel,  99,  159,  183 
Potentia  coeuudi.  111,  112 
Potentia  generandi.  111,  112 
Pressure,  conditions  of,  in  paresis  of  bladder,  65 

negative,   dangers  of,   in  connection  with  catheteriza- 
tion, 68 
Prostate,  diseased  conditions  of,  106,  161,  171 

diagnosis,  172 

symptoms,  172 

treatment,  183,  184 
Prostatie  shreds,  26,  51,  161,  174 
Prostaiic  urethra,  catarrh  of,  9,  27,  46,  93,  151,  167,  170,  174 


lOG  LuJex. 

Prostatic  tirethra,  catarrh  of,  treatment  of,  28,  137,  1P2 

hypenEinia  of,  9,  27,  46,  92,  165,  167,  174 

hypersesthesia   of.   10,   27,   31,   46,   92,    106,   153,   165, 
175,  188 
Prostatitis,  follicular,  161,  167,  172,  175 

treatment  of,  183,  184 
Prostatorrh(t!a,  104,  170 

cause,  105 

diagnosis,  105 

examination  with  sounds,  106 

prognosis,  106 

symptoms,  105 

treatment,  107,  162 
Psychical  impotence,  32,  148,  165 

Psychrophor  of  Winternitz,  or  cold  sound,  in  treatment  of 
impotence,  42,  158,  182 

of  spermatorrhoea,  98 

Quinine  in  treatment  of  cystospasm,  52 
of  impotence,  156 
of  paresis  of  bladder,  62 
of  spermatorrhoea,  96 

Rectal  electrode,  37,  40,  80,  107,  160,  183 
Relative  impotence,  32,  151 
Retention  of  urine,  57,  161 

Secretion  of  prostate,  136 
Secretory  neuroses,  25,  103 
Semen,  color  of,  89,  124 
blue,  89,  127 
brownish  yellow,  124,  127 
green,  127 

red  or  reddish  brown,  89,  124 
violet  or  wine-colored,  89,  126 
yellow,  89,  125 

in  azoospermia,  90,  131 
in  oligozo(")spermia,  128 
normal,  83,  113 
IKithological  changes  of,  116 
Seminal  granules,  113 
Sensory  neuroses,   25,  31 

Sexual  excess,  33,  92,  105,  120,  149,  153,  154,  166 
Sexual  perversion,  1G8 
Sounds  in  examination  of  prostate,  47 

in  treatment  of  follicular  prostatitis,  183 
of  impotence,  42,  157,  181 


Index.  197 


Sounds  in  treatment  of  spasm  of  sphincter,  48 

of  spermatorrhoea,  97 
Spasmodic  stricture,  45,  161 
Spasmus  detrusorum  vesicae,  48 

sphincteris  vesicae,  44 
Spermatic  cells,  113 

crystals,  85,  91,  132 
Spermatin,  113 
Spermatorrhoea,  81 

causes  of,  92 

causing  impotence,  32,  169 

diagnosis  of,  93 

symptoms  of,  94 

treatment  of,  95,  162 
Spermatozoa,  23,  84,  113,  169 

abnormal  and  pathological  forms,  135 

in  normal  semen,  84,  113 

in  vesiculitis,  89,  134,  173 

motionless,  89,  135,  173 

relative  numbers  of,  127 
Sphincter  of  bladder,  27,  29,  44,  46,  53,  59,  76 
Sterility,  112 

treatment  of,  137 
Strangury,  61 

Strychnia  in  paresis  of  bladder,  62 
Sulphate-of-zinc  injections,  29 
Syringe-catheter  of  Ultzmann,  28 

Tannin  injections,  30 

suppositories,  100,  159 

Urethra,  hypersesthesia  of,  25,  26 

neuralgia  of,  25,  26 
Urethral  dropper  of  Ultzmann,  137 
Urinary  fever,  65,  162 
Urine  in  neuroses,  12 
character  of,  13 
constituents  of,  14 
albumen,  20 
carbonate  of  soda,  16 
indican,  19 
phosphates,  18 
alkaline,  18 
earthy,  17 
sugar,  15, 
reaction,  16 
acid,  17 


198  Index. 

Urine,  reaction,  alkaline,  16 

neiitml,  16 
sediment,  20 

ciiibonate  of  lime,  22 

indiji;o,  23 

oxalate  of  lime,  21 

phosphate  of  lime,  amorphous,  22 
crystalline,  23 

phosphate  of  magnesia,  23 

spermatozoa,  23 
Urotropin,  161 

Valerian  in  treatment  of  spermatorrhoea,  96 
Vas  deferens,  ampulla  of,  171,  173,  184 
A^eru  montanum,  9,  42,  92,  122,  143,  167,  174,  183 
Vesi^uliE  semiuales,  81,  145 

inflammation  of,  35,  89,  124,  134,  169,  170,  174 

diagnosis,  172 

symptoms,  171 

treatment,  184 


RC872                     Ul8 

Ultznann 

Neuroses  of  the  eenito_urinGrv  svl-. 

